CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 03/01/2021 VERIFIED: 03/30/2021 REVIEWED: 03/30/2021 TOPICAL CORTICOSTEROIDS Prior Authorization Override Request PHARMACY FAX # 844-256-2025 • Pertinent office notes and past medical history must be submitted with the prior authorization request.

PATIENT INFORMATION Patient Name Date

Paramount ID DOB Gender: M/F

Medication Allergies

PROVIDER INFORMATION Prescriber Name NPI # DEA #

Prescriber Specialty Prescriber Address

Office Fax Phone Office Contact Name

MEDICATION REQUESTED Drug Name Strength Directions (Sig)

Duration of Therapy: Quantity Diagnosis Days: Months: Are you requesting brand (DAW): _ NO _ YES *PLEASE NOTE DAW REQUESTS REQUIRE RATIONALE- SEE BELOW

Is the Patient currently being treated with this medication?  Yes; Date started mm/dd/yy / /  No

(alclometasone cream, ointment – generic of APEXICON-E (diflorasone diacetate emollient base (betamethasone dipropionate augmented cream, Aclovate) cream) ointment, lotion, gel – generic of Diprolene AF) (betamethasone dipropionate cream, ointment, BRYHALI (halobetasol proprinate lotion) CAPEX (fluocinolone acetonide shampoo) lotion – generic of Diprolene) CLOBEX (clobetasol propionate lotion, shampoo) (clocortolone pivalate – generic of Cloderm) CLODAN (clobetasol propionate shampoo, kit) CORDRAN (flurandrenolide tape) DESONATE (desonide gel) (desonide lotion – generic of Desowen) (desoximetasone cream, gel, ointment – generic (fluocinolone acetonide 0.025% cream, ointment – (fluocinonide cream – generic of Vanos) of Topicort) generic of Synalar) (fluticasone propionate lotion – generic of (halobetasol propionate cream, ointment – generic HALOG (halcinonide cream, ointment) Cutivate) of Ultravate) (hydrocortisone acetate/aloe gel) (hydrocortisone butyrate cream, ointment, solution (hydrocortisone/urea cream – generic of Carmol – generic of Locoid) HC) (hydrocortisone valerate cream, ointment – IMPEKLO (clobetasol propionate) KENALOG AEROSOL SPRAY (triamcinolone generic of Westcort) acetonide) LEXETTE (halobetasol propionate foam) LUXIQ (betamethasone valerate foam) OLUX-E (clobetasol propionate foam) PANDEL (hydrocortisone probutate cream) PEDIADERM HC KIT (hydrocortisone) (prednicarbate ointment – generic of Dermatop) SERNIVO (betamethasone dipropionate spray)

MEDICAL JUSTIFICATION: Include Other Relevant Medications Tried and Results Please indicate previous treatment and outcomes below Previous Medication Strength Qty Directions (Sig) Dates (mmddyy to mmddyy) Reason for Discontinuation 1

2

3

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 03/01/2021 VERIFIED: 03/30/2021 REVIEWED: 03/30/2021 4

CRITERIA FOR APPROVAL

1 Has the patient experienced an inadequate treatment response of 14 day trials of TWO Yes No preferred medications within the same potency category (which do not require prior approval)? [If yes, then skip to question 3.]

2 Is the patient unable to be changed to a preferred medication (which does not require Yes No prior approval) for any of the following acceptable reasons: A) Allergy to at least TWO preferred medications, B) Contraindication to ALL preferred medications, C) History of unacceptable or toxic side effects to at least TWO preferred medications?

3 Is this a request for a low or medium potency corticosteroid? Yes No [If yes, then no further questions.]

4 Is this a request for a high or very high potency corticosteroid? Yes No

RELEVANT MEDICAL RATIONALE FOR REQUEST/ADDITIONAL CLINICAL INFORMATION INCLUDING WHY PATIENT REQUIRES BRAND OVER GENERIC. (Attach Relevant Lab Results and Chart Notes)*

*In order to process this request, please complete all boxes completely.

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