Topical

PA criteria:

• 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)

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.
  • a. 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.).

• 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 0.1% (Vanos® C)
• halobetasol propionate (Halonate® F)
• halobetasol propionate/lactic acid (Ultravate® X C)
• halcinonide (Halog® C,O)

•  
• 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)

•  
• alclometasone dipropionate (Aclovate® C,O)
• fluocinolone acetonide 0.01% (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)
• hydrocortisone/pramoxine (C,O)

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.

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.

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, recent trials of at least two Tier-1 topical antifungal products for at least 90 days each; AND
• When the same medication is available in Tier-1, a patient-specific, clinically significant reason must be provided for using a special dosage form of that medication in Tier-2 (foams, shampoos, sprays, kits, etc.).
• Authorization of combination products nystatin/triamcinolone or clotrimazole/betamethasone requires a patient-specific, clinically significant reason why the member cannot use the individual components separately.
• For treatment of onychomycosis, a trial of oral antifungals (6 weeks for fingernails and 12 weeks for toenails) will be required for consideration of approval of Penlac® (ciclopirox solution).
  

efinaconazole (Jublia®) and tavaborole (Kerydin™) Approval Criteria:

• An FDA approved diagnosis of onychomycosis of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes; AND
• A trial of oral antifungals (12 weeks for toenails); AND
• A patient-specific, clinically significant reason why member cannot use Penlac® (ciclopirox solution); AND
• A clinically significant reason the member requires treatment for onychomycosis (cosmetic reasons will not be approved).

• ciclopirox-0.77%
• clotrimazole (Rx) cream, solution
• clotrimazole 1% cream (OTC)*
• econazole 1% cream
• ketoconazole 2% cream, shampoo
• nystatin cream, ointment, powder
• terbinafine 1% cream (OTC)*
• tolnaftate 1% cream (OTC)*

• butenafine (Mentax®
• ciclopirox solution, shampoo & gel (Loprox® and Penlac®)
• clotrimazole/betamethasone-1% & 0.05% cream, lotion
• ketoconazole foam 2% (Extina®)
• ketoconazole gel (Xolegel®)
• luliconazole 1% cream (Luzu®)
• miconazole/zinc oxide/white petrolatum (Vusion®)
• naftifine (Naftin®)
• nystatin/triamcinolone-cream, ointment
• oxiconazole (Oxistat®)
• salicylic acid (Bensal HP®)
• sertaconazole nitrate (Ertaczo®)
• sulconazole (Exelderm®)

• efinaconazole (Jublia®)
• tavaborole (Kerydin™)

PA criteria:

• Member unable to swallow tablets, and
• FDA-approved indication and
• No improvement after at least 3 weeks of therapy with griseofulvin, or
• Intolerance of hypersensitivity to griseofulvin or penicillin

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.

• 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%

Tier 1 products are available without prior authorization.

Approval Criteria:

• 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.

• Covered OTC Permethrin 1% liquid
• ivermectin (Sklice®)

• spinosad (Natroba®)
• benzoyl alcohol (Ulesfia®) lotion

• Lindane lotion and shampoo
• malathion (Ovide®) brand and generic

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.