Topical

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

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

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™)

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

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%

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

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

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  

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