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Topical

pimecrolimus (Elidel®) tacrolimus (Protopic®)
  • Clinical Diagnosis: short term and intermittent treatment for mild to moderate atopic dermatitis (eczema).
  • The first 90 days of a 12 month period will be covered without a prior authorization.
  • After the initial period, authorization will be granted with documentation of one trial of a tier 1 topical corticosteroid of six weeks duration within the past 90 days.
  • Therapy will be approved only once each 90 day period to ensure appropriate short-term and intermittent utilization as advised by the FDA.
  • Quantities will be limited to 30 grams for use on the face, neck, and groin, and 100 grams for all other areas.
  • Authorizations will be restricted to those patients who are not immunocompromised.
  • Exception for age restrictions granted only if prescription is written by a dermatologist.
  • Age restrictions:
    • Elidel 1% ≥2 years of age
    • Protopic 0.03% for ≥2 years of age
    • Protopic 0.1% for ≥15 years of age (Approved for adult-use only)
Topical Corticosteroids

Tier 1 products are available with no authorization necessary.

Criteria:

  • Documented trials of ALL tier 1 topical corticosteroids of similar potency in the past 30 days that did not yield adequate relief.
    • If tier 1 trials are completed and do not yield adequate relief, the member must also provide a clinical reason for requesting a tier 2 in the same potency instead of trying a higher potency.
  • When the same medication is available in tier 1, a clinical reason must be provided for using a special dosage form of that medication in tier 2 (foams, shampoos, sprays, kits, etc.).
Tier 1
Tier 2
Ultra high to high potency
  • augmented betamethasone dipropionate .05% (Diprolene® A.F., C,G)
  • clobetasol propionate 0.05% (C,G,O,So)
  • fluocinonide 0.05% (C,O)
  • halobetasol propionate (Ultravate® C,O)
  • betamethasone dipropionate (C,O)
  • fluocinonide 0.05% (G,So)
  • diflorasone diacetate 0.05% (C, ApexiCon E® C, O)amcinonide (C,O,L)
  • augmented betamethasone dipropionate (Diprolene® O,L)
  • clobetasol propionate 0.05% (Clobex® L,Sh,Spr: Olux® F Olux-E™ F)
  • desoximetasone 0.25% (Topicort® C,O) 0.05% (G)
  • fluocinonide 0.01% (Vanos® C)
  • halobetasol propionate (Halonate® F)
  • halobetasol propionate/lactic acid (Ultravate® X C)
  • halcinonide (Halog® C,O)
Med/high to medium potency
  • betamethasone dipropionate (L)
  • betamethasone valerate 0.1% (C)
  • fluocinonide emollient (C)
  • fluticasone propionate (Cutivate® C,O)
  • mometasone furoate 0.1% (Elocon® C,L)
  • triamcinolone acetonide (Pediaderm™, Trianex™ C,O,L)
  • Hydrocortisone valerate 0.2% (C)
  • mometasone furoate 0.01% (O)
  • betamethasone valerate 0.01% (O,L)
  • fluocinolone acetonide 0.025% (Synalar® C,O)
  • hydrocortisone valerate 0.2% (O)
  • betamethasone dipropionate/calcipotriene (Taclonex® O,Sus, Spr)
  • betamethasone valerate 0.12% (Luxiq® Foam)
  • desoximetasone 0.05% (Topicort LP® C)
  • flurandrenolide tape (Cordan®)
  • fluticasone propionate (Cutivate® L)
  • hydrocortisone butyrate 0.1% So
  • hydrocortisone probutate (Pandel® C)
  • hydrocortisone valerate (Westcort® C,O)
  • prednicarbate (Dermatop® O,C)
  • triamcinolone acetonide (Kenalog® Spr)
Low potency
  • alclometasone dipropionate (Aclovate® C,O)
  • fluocinolone acetonide 0.1% (Synalar So, C; Derma-Smooth; Derma-Smooth FS® oil)
  • hydrocortisone acetate 2.5% (C,O,L)
  • hydrocortisone/urea (U-Cort® C)
  • coclortolone pivalate (Cloderm® C)
  • desonide 0.05% (Desonate G, Verdeso® F, L)desonide 0.05% (C,O)
  • desonide/emollient (Desowen® kit C, O)
  • fluocinolone acetonide 0.01% (Capex® Sh)
  • hydrocortisone/lidocaine (C)
C=cream, O=ointment, L=lotion, G=gel, Sh=shampoo, Spr=spray, F=foam, So=scalp oil
capsaicin 8% (Qutenza®) Patch

PA criteria:

  • Available through Medical claims only. FDA approved diagnosis.
  • Provide documented treatment attempts at recommended dosing or contraindication to at least one agent from each of the following drug classes:
    • Tricyclic antidepressants
    • Anticonvulsants
    • Topical Lidocaine
  • Quantity limit of no more than 4 patches per treatment every 90 days.
  • Product must be administered by a healthcare provider.
  • Outpatient/Physician Prior Authorization Form
lidocaine (Lidoderm®) Patch

PA criteria:

  • FDA approved diagnosis
  • Provide documented treatment attempts at recommended dosing or contraindication to at least one agent from two of the following drug classes:
    • Tricyclic antidepressants
    • Anticonvulsants
    • Topical or Oral Analgesics
  • Quantity limit of no more than 3 patches per day with a maximum of 90 patches in a month.
  • Prior Authorization form
Antifungal Step Therapy

Tier 1 products are covered with no authorization necessary

  • OTC products require a prescription.
  • OTC products are covered for members age 0-20 years. For members age 21 and older, please use other Tier 1 products.

Criteria for Tier 2 Product:

  • Documented trials of at least two Tier 1 topical antifungal products within the last 30 days.
  • For treatment of Onychomycosis, a trial of oral antifungals (6 weeks for fingernails and 12 weeks for toenails) is required prior to approval of Penlac®.
Tier 1 Tier 2
  • ciclopirox-0.77%
  • clotrimazole 1% cream (OTC)
  • econazole 1% cream
  • ketoconazole 2% cream, shampoo
  • clotrimazole cream, solutionnystatin cream, ointment
  • terbinafine 1% cream (OTC)
  • tolnaftate 1% cream (OTC)
  • clotrimazole/betamethasone-1% & 0.05% cream, lotion
  • nystatin/triamcinolone-cream, ointment
  • sertaconazole nitrate (Ertaczo®)
  • sulconazole (Exelderm®)
  • ketoconazole foam 2% (Extina®)
  • ciclopirox solution, shampoo & gel (Loprox® and Penlac®)
  • butenafine (Mentax®)
  • naftifine (Naftin®)
  • oxiconazole (Oxistat®)
  • ketoconazole gel (Xolegel®)
  • miconazole/zinc oxide/white petrolatum (Vusion®)
Topical Antibiotic Medications

Tier 1 products are available without prior authorization.

Tier 2 authorization requires:

  • Documented five-day trial of a Tier 1 product within the last 30 days.
  • Clinical exception for adverse effects with all Tier 1 products, or unique indication not covered by Tier-1 products.
  • Prior authorization will be for 10 days.
Tier 1 Tier 2
  • Cortisporin Cream 0.5%
  • Cortisporin Ointment 1%
  • Gentamicin Cream 0.1%
  • Gentamicin Ointment 0.1%
  • Gentamicin Powder
  • Mupirocin Ointment 2%
  • Altabax Ointment 1%
  • Bactroban Cream 2%
  • Bactroban Nasal Ointment 2%
  • Centany Kit 2%
Pediculicide

Tier 1 products are available without prior authorization.

Tier 2 Authorization Criteria:

  • A trial with a tier 1 medication with inadequate response or adverse effect.

Tier 3 Authorization Criteria:

  • Trials with all available tier 2 medications with inadequate response or adverse effect.
Tier 1 Tier 2
Tier 3
  • Covered OTC Permethrin 1% liquid
  • spinosad (Natroba®)
  • benzoyl alcohol (Ulesfia®) lotion
  • ivermectin (Sklice®)
  • Lindane lotion and shampoo
  • malathion (Ovide®) brand and generic
Crotamiton lotion (Eurax®)

PA Criteria:

  • Diagnosis of Scabies.
  • Member must be at least 18 years of age,
  • Member must have used Permethrin 5% in the past 7-14 days with inadequate results,
  • Quantity limits apply.
Last Modified on Jul 19, 2021
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