MEDICARE PART D STEP THERAPY CRITERIA

diflorasone diacetate 0.05% Plan Limitations:  Does not apply to the following Blue Shield of California Medicare Part D plans: o Blue Shield 65 Plus (HMO) in Fresno, Kern, San Luis Obispo, Santa Barbara, and Ventura counties o Blue Shield 65 Plus Choice Plan (HMO) o Blue Shield 65 Plus (HMO) in Los Angeles, Orange, and San Bernardino counties o Blue Shield 65 Plus (HMO) in Riverside, and San Diego counties o Blue Shield 65 Plus (HMO) in Sacramento County o Blue Shield Medicare Basic Plan (PDP) o Blue Shield Medicare Enhanced Plan (PDP)

Step Therapy Criteria:

1) Step One:  medium, high, or very high potency topical corticosteroid agents (amcinonide 0.1% (lotion, cream, ointment), betamethasone dipropionate 0.05% (lotion, cream, ointment), betamethasone valerate 0.1% (lotion, cream, ointment), augmented betamethasone 0.05% (lotion, cream, gel, ointment), clobetasol 0.05% (lotion, solution, shampoo, cream, foam, gel, ointment, spray, emollient cream, emollient foam), clocortolone pivalate 0.1% cream, desoximetasone 0.05% (cream, gel, ointment), desoximetasone 0.25% (cream, ointment), diflorasone 0.05% (cream, ointment), fluocinolone 0.01% (cream, solution), fluocinonide 0.05% (cream, gel, ointment, solution), fluocinonide 0.1% cream, fluticasone 0.05% lotion, halobetasol propionate 0.05% (cream, ointment), hydrocortisone butyrate 0.1% cream, hydrocortisone valerate 0.2% (cream, ointment), mometasone 0.1% (cream, ointment, solution), prednicarbate 0.1% (cream, ointment), triamcinolone acetonide 0.1% (lotion, cream, ointment), triamcinolone acetonide 0.147mg/gram topical aerosol), triamcinolone acetonide 0.5% (cream, ointment)

2) Step Two:  If any claims history of two step one drugs within the past 180 days, then diflorasone diacetate 0.05% is approved for coverage.

Coverage Duration: Annual

Updated 01/2017