Topical 2017 Archives

PA criteria:

• An FDA approved indication for treatment of mild-to-moderate atopic dermatitis (eczema); AND
• Member must be at least 2 years of age or older; AND
• Member must have documented trials within the last six months for a minimum of two weeks that resulted in failure with both of the following therapies (or have a contraindication or documented intolerance):
  
  • One Tier-1 topical corticosteroid; AND
  • One topical calcineurin inhibitor [e.g., Elidel® (pimecrolimus), Protopic® (tacrolimus)]; AND
• A quantity limit of one tube per 30 days will apply.
• Initial approvals will be for the duration of one month. Reauthorization may be granted if the prescriber documents the member is responding well to treatment.  

Prior Authorization form

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

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, 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™)

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 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

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

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  

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  

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  

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  

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  

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  

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