betamethasone valerate (LUXIQ) 0.12% foam CAPEX (fluocinolone acetonide) clocortolone pivalate (CLODERM) 0.1% cream CORDRAN (flurandrenolide) tape, 0.025% cream, 0.05% ointment Desonate gel (desonide 0.05% gel) flurandrenolide (CORDRAN) 0.05% lotion fluticasone (BESER, CUTIVATE) 0.05% lotion hydrocortisone butyrate (LODOID) 0.1% cream, 0.1% lipocream PANDEL (hydrocortisone probutate 0.1% cream) triamcinolone acetonide (TRIANEX) 0.05% ointment
Diagnosis Considered for Coverage: • Relief of the inflammatory and pruritic manifestations of corticosteroid responsive dermatoses
Coverage Criteria:
For brand-name formulations Luxiq, Cloderm, Cutivate, Locoid, Trianex: • Meets coverage criteria below for generic formulation, and • Allergic or intolerable side effect to the generic formulation.
For generic formulations betamethasone valerate (Luxiq), clocortolone pivalate (Cloderm), fluticasone (Cutivate), hydrocortisone butyrate (Locoid), Pandel, triamcinolone acetonide (Trianex): • For diagnosis listed above, and • Inadequate response or intolerance to TWO preferred generically available topical corticosteroids from the medium to very high potency group.
For brand-name formulations Capex, Cordran, Desonate: • Inadequate response or intolerance to TWO preferred generically available topical corticosteroids from the medium to very high potency group.
Preferred Corticosteroids • alclometasone 0.05% cream, ointment (Aclovate) • betamethasone valerate 0.1% lotion (Valisone) • fluocinolone 0.01% oil (Derma-Smoothe-FS) Low Potency • hydrocortisone 1%/iodoquinol (Vytone) • hydrocortisone 2.5% cream, ointment, lotion (Hytone) • triamcinolone acetonide 0.025% cream, lotion, ointment (Kenalog) • betamethasone dipropionate 0.05% lotion (Maxivate, Diprosone) • betamethasone valerate 0.1% cream (Betatrex, Valisone) • desoximetasone 0.05% cream (Topicort LP) • fluocinolone 0.025% cream, ointment Medium • fluocinolone 0.01% solution (Synalar) Potency • hydrocortisone valerate 0.2% cream, ointment (Westcort) • mometasone furoate 0.1% cream, ointment, lotion (Elocon) • prednicarbate 0.1% cream, ointment (Dermatop) • triamcinolone acetonide 0.1% cream, ointment, lotion (Kenalog) • augmented betamethasone dipropionate 0.05% cream (Diprolene AF) • betamethasone dipropionate 0.05% cream, ointment (Maxivate, Diprosone) High Potency • betamethasone valerate 0.1% ointment (Betatrex, Valisone) • fluocinonide 0.05% cream (Lidex E)
• fluocinonide 0.05% cream, gel, ointment, solution (Lidex) • triamcinolone acetonide 0.5% cream (Kenalog) • triamcinolone acetonide 0.5% ointment (Aristocort HP) • augmented betamethasone dipropionate 0.05% gel, ointment, lotion Very High (Diprolene) Potency • clobetasol 0.05% cream, ointment, solution, gel, cream emollient (Temovate) • halobetasol 0.05% cream, ointment (Ultravate)
Coverage Duration: 1 year Effective: 1/01/2020GF