Skip to main content

SoonerSelect enrollment is open through June 13! It’s your chance to pick or change your health and dental plans. Make changes in the member portal or call 800-987-7767.

Topical

pimecrolimus (Elidel®) tacrolimus (Protopic®)

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)
  • Prior Authorization form

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.

    • 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.).
  • Prior Authorization form

Tier 1

Tier 2

Ultra high to high potency

  • augmented betamethasone dipropionate .05% (Diprolene® A.F.) C
  • augmented betamethasone dipropionate .05% (Diprolene®) G
  • betamethasone dipropionate ( Diprosone®) O
  • fluocinonide 0.05% C,O, So
  • halobetasol propionate (Ultravate®) C
  • amcinonide C,O,L
  • augmented betamethasone dipropionate (Diprolene®) O,L
  • betamethasone dipropionate C
  • clobetasol propionate 0.05% (Clobex®) L,Sh,Spr (Olux®) F (Olux-E™) F
  • clobetasol propionate 0.05% (Temovate®) C, G, O,So
  • desoximetasone 0.25% (Topicort®) C,O 0.05% (G)
  • desoximetasone 0.25% (Topicort®) C,O, Spr
  • desoximetasone 0.05% (Topicort®) G
  • fluocinonide 0.05% (G)
  • diflorasone diacetate 0.05%( ApexiCon) C (ApexiCon E®) C, O
  • fluocinonide 0.05% G
  • fluocinonide 0.1% (Vanos®) C
  • halcinonide (Halog®) C,O
  • halobetasol propionate 0.05% (Ultravate®) O, L
  • halobetasol propionate/lactic acid (Ultravate® X) C 

Med/high to medium potency

  • betamethasone dipropionate (Betamate®) L
  • betamethasone valerate 0.1% (Beta-Val®) C, L, O
  • fluticasone propionate (Cutivate®) C,O
  • mometasone furoate 0.1% (Elocon®) C,L


  • betamethasone dipropionate 0.05% (Sernivo™) Spr
  • betamethasone dipropionate/calcipotriene (Taclonex®) O,Sus, Spr
  • betamethasone valerate 0.12% (Luxiq®) F
  • calcipotriene/betamethasone dipropionate (Enstilar®)  F
  • desoximetasone 0.05% (Topicort LP®) C
  • fluocinolone acetonide 0.025% (Synalar®) C,O
  • fluocinonide emollient (Lidex E®) C
  • flurandrenolide tape (Cordan®)
  • flurandrenolide 0.05% C, L
  • fluticasone propionate (Cutivate®) L
  • hydrocortisone butyrate 0.1% C, O, So
  • hydrocortisone probutate (Pandel®) C
  • hydrocortisone valerate 0.2% C, O
  • hydrocortisone valerate 0.2% (Westcort®) C,O
  • mometasone furoate 0.01% O
  • prednicarbate (Dermatop®) C, O
  • triamcinolone acetonide (Kenalog®) Spr

Low potency

  • alclometasone dipropionate (Aclovate®) C,O
  • fluocinolone acetonide 0.01% (Synalar®) C
  • hydrocortisone acetate 2.5% C,L, O
  • hydrocortisone/urea (U-Cort®) C
  • coclortolone pivalate (Cloderm®) C
  • desonide 0.05% (Desonate®) G 
  • desonide 0.05% C,O
  • desonide 0.05% (Verdeso®) F, L
  • desonide/emollient (Desowen® kit) C, O
  • fluocinolone acetonide 0.01% (Capex®) Sh; (Synalar) So; (Derma-Smooth, Derma-Smooth FS®) Oil
  • hydrocortisone 2.5% (Texacort®) So
  • hydrocortisone/pramoxine (Pramosone®) C,L

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, 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 cream, nystatin/triamcinolone ointment, or clotrimazole/betamethasone lotion requires a patient-specific, clinically significant reason why the member cannot use the individual components separately, or in the case of clotrimazole/betamethasone lotion why Tier-1 cream cannot be used.
  • 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).

Tier 1

Tier 2

Special PA

  • ciclopirox cream, suspension
  • clotrimazole (Rx) cream
  • clotrimazole 1% cream (OTC)*
  • clotrimazole/betamethasone 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®)
  • clotrimazaole solution
  • clotrimazole/betamethasone lotion
  • econazole cream
  • ketoconazole foam 2% (Extina®)
  • ketoconazole gel (Xolegel®)
  • luliconazole 1% cream (Luzu®)
  • miconazole/zinc oxide/white petrolatum (Vusion®) 
  • efinaconazole (Jublia®)
  • tavaborole (Kerydin)

*Over-the-counter(OTC) antifungal products are covered for pediatric members 0-20 years of age without prior authorization.

terbinafine (Lamisil®) Granules

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
  • Prior Authorization form
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.

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.
  • Prior Authorization form

Tier 1

Tier 2

Tier 3

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

  • Lindane 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.
  • Prior Authorization form

 

diclofenac 3% gel (Solaraze®)

PA Criteria:

  • An FDA approved diagnosis of actinic keratosis (AK); AND
  • Patient-specific information must be documented on the prior authorization form, including all of the following:
    • Number of AK lesions being treated; AND
    • Sizes of each lesion being treated; AND
    • Anticipated duration of treatment; AND
  • Approval quantity and length will be based on patient-specific information provided, in accordance with Solaraze® prescribing information and FDA approved dosing regimen. 

Prior Authorization form  

imiquimod (Zyclara®) 

PA Criteria:

  • An FDA approved diagnosis of actinic keratosis (AK) of the full face or balding scalp in immunocompetent adults or topical treatment of external genital and perianal warts/condyloma acuminata (EGW) in patients 12 years and older; AND
  • Member must be 12 years or older; AND
  • Requests for a diagnosis of molluscum contagiosum in children 2 to 12 years of age will generally not be approved; AND
  • A patient-specific, clinically significant reason why the member cannot use generic imiquimod 5% cream in place of Zyclara® (imiquimod) 2.5% and 3.75%. 

Prior Authorization form  

Last Modified on Mar 20, 2025
Back to Top