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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 Dec 02, 2020
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