VA CFU Criteria Formulary Advisor Reference
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TIRBANIBULIN OINT,TOP

Generic Name
TIRBANIBULIN OINT
Brand Names
KLISYRI
Drug Class
ANTIACNE AGENTS,TOPICAL
Formulary Status
N
Copay Tier
3
Last Updated
2021-01-28

Clinical Criteria Summary

Exclusion Criteria

  • None
  • Inclusion Criteria (All criteria must be fulfilled)
  • Care is provided by a VA / VA Community Care dermatologist or locally designated expert in actinic keratosis (AK)
  • Clinically typical AK of the face or scalp
  • Inadequate response or intolerance to two of three topical field therapies (5-fluorouracil, imiquimod, or diclofenac 3%) unless the treatment is medically inadvisable
  • Inadequate response or intolerance to aminolevulinic acid with photodynamic therapy unless the treatment is medically inadvisable, unfeasible, or unavailable

Source Documents

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