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 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, solution
• nystatin 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®)

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

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

• ivermectin (Sklice®)
• 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.
• Prior Authorization form