Limited Coverage Drugs - Alitretinoin

Generic Name



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


  • If the eczema remains severe at 12 weeks


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

Special Authority Request Form(s)