Limited Coverage Drugs - Alitretinoin

Generic Name

alitretinoin

Strength

10 mg, 30 mg
Form Capsule

Special Authority Criteria

Approval Period

For the treatment of severe chronic hand eczema in patients meeting ALL the following criteria:

  1. Refractory to 2 months of high or ultra-high potency topical steroids
  2. Dermatology Life Quality Index equal to or greater than 15
  3. Prescribed by a dermatologist.

24 weeks

Practitioner Exemptions

  • None

Special Notes

  1. High or ultra high potency corticosteroids include: clobetasol proprionate 0.05%, betametasone dipropionate 0.05%, betamethasone dipropionate glycol 0.05%, desoximetasone 0.25%, fluocinonide 0.05%, halcinonide 0.1%, halobetasol propionate 0.05% and amcinonide 0.1%
  2. The Dermatology Life Quality Index (DLQI) is a 10-question validated questionnaire designed to measure how dermatology-specific issues affect a patient’s quality of life. The 10 questions are measured according to a three-point scale. Sum-total DLQI scores and their meaning for patients are as follows:
    • 0-1 = no effect at all on patient's life
    • 2-5 = small effect on patient's life
    • 6-10 = moderate effect on patient's life
    • 11-20 = very large effect on patient's life
    • 21-30 = extremely large effect on patient's life
  3. The need for continued alitretinoin treatment should be reassessed:
    • As soon as an adequate response (hands clear or almost clear) has been achieved

OR

  • If the eczema remains severe at 12 weeks

OR

  • If an adequate response (hands clear or almost clear) has not been achieved by 24 weeks

Special Authority Request Form(s)