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)
     
 

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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
  • diflorasone diacetate 0.05%( ApexiCon) C (ApexiCon E®) C, O
  • fluocinonide 0.05% G
  • fluocinonide 0.1% (Vanos®) C
  • flurandrenolide tape (Cordan®)
  • 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
  • triamcinolone acetonide C, L, O


 
  • 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, O
  • fluocinolone acetonide 0.025% (Synalar®) C,O
  • fluocinonide emollient (Lidex E®) C
  • 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

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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
 

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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

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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
 

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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%
 

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Pediculicide

Tier 1 products are available without prior authorization.

Approval Criteria:

  • Tier 2 Authorization Criteria
    • A trial with all available Tier 1 medication with inadequate response or adverse effect.
    • Clinical exception applies if there is known resisitance to OTC permethrin or pyrethrin

    • Prior Authorization form  
     
 

Tier 1

Tier 2

  • 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
 
 

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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  

 

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dapsone gel (Aczone®

PA Criteria:

  • An FDA approved indication of acne vulgaris; AND
  • Member must be 20 years of age or younger; AND
  • A previous trial of benzoyl peroxide or a patient-specific, clinically significant reason why benzoyl peroxide is not appropriate for the member; AND
  • A previous trial of a topical antibiotic, such as clindamycin or erythromycin, or a patient-specific, clinically significant reason why a topical antibiotic is not appropriate for the member. 

Prior Authorization form  

 

 

 

         

 
tazarotene cream and gel (Tazorac®)

PA Criteria:

  • An FDA approved indication of acne vulgaris or plaque psoriasis; AND
  • Female members must not be pregnant and must be willing to use an effective method of contraception during treatment; AND
  • Authorization of generic tazarotene (in place of brand Tazorac®) will require a patient-specific, clinically significant reason why the member cannot use the brand formulation (brand formulation is preferred); AND
  • For a diagnosis of acne vulgaris, the following must be met:
    • Member must be 20 years of age or younger; AND
     
  • A quantity limit of 60 grams per 30 days will apply.

Prior Authorization form  

 

 

 
ingenol mebutate gel (Picato®)

PA Criteria:

  • An FDA approved diagnosis of actinic keratosis (AK); AND
  • Member must be 18 years of age or older; AND
  • Patient-specific information must be documented on the prior authorization form, including all of the following:
    • Number of AK lesions being treated; AND
    • Size of each lesion being treated; AND
    • Location of lesions being treated; AND
     
  • Approval quantity and length will be based on patient-specific information provided, in accordance with Picato® prescribing information and FDA approved dosing regimen.

Prior Authorization form  

           

        

doxepin cream (Prudoxin™ and Zonalon®)

PA criteria:

  • An FDA approved diagnosis for the short-term (up to eight days) management of moderate pruritus in patients with atopic dermatitis or lichen simplex chronicus; AND
  • Requests for longer use than eight days will not generally be approved. Chronic use beyond eight days may result in higher systemic levels and should be avoided. 

Prior Authorization form  

 

 
fluorouracil 0.5% cream (Carac®)

PA Criteria:

  • An FDA approved diagnosis of multiple actinic or solar keratoses of the face and anterior scalp in adults; AND
  • Carac® must be prescribed by a dermatologist or an advanced care practitioner with a supervising physician who is a dermatologist; AND
  • A patient-specific, clinically significant reason why the member cannot use fluorouracil 5% cream, fluorouracil 5% solution, or fluorouracil 2% solution.

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  

 

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