Diagnosis: Atopic dermatitis.
Treatment: Opzelura 1.5% (percent) External (EX) Cream.
The insurer denied coverage for Opzelura 1.5% External (EX) Cream.
The denial is overturned.

The patient is an adult female with a history of atopic dermatitis. The patient has failed therapy with topical steroids as well as systemic Dupixent, Cellcept, and Hydroxyzine. The request is for topical Opzelura as a formulary exception for treatment of atopic dermatitis.

Based on the submitted documentation, the use of Opzelura to treat atopic dermatitis is medically necessary. The patient has failed multiple topical therapies for the treatment of atopic dermatitis as well as several systemic agents, including Dupixent and mycophenolate. Opzelura is Food and Drug Administration (FDA) approved for atopic dermatitis treatment and its use would be expected to be more effective than formulary alternatives. Formulary alternatives have thus far been ineffective for this patient and the use of Opzelura is not expected to have greater side effects than formulary alternatives. The use of Opzelura is approved as a formulary exception based on the documentation submitted.

The formulary drugs are not expected to cause adverse effects.

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives.
The carrier's denial of a request for a Formulary Exception for Opzelura 1.5% (percent) |(External) EX Cream to treat atopic dermatitis is overturned.