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

 

 

Med/high to medium potency 

  • 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)
 

Low potency 

  • alclometasone dipropionate (Aclovate® C,O)
  • fluocinolone acetonide 0.1% (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)
 

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 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®)
 
terbinafina (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
 
  • spinosad (Natroba®)
  • benzoyl alcohol (Ulesfia®) lotion
 
  • ivermectin (Sklice®)
  • Lindane lotion and 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 
 

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Dec 02, 2020
Back to Top