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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
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