propionate (Clobex) 0.05% lotion, shampoo, spray clobetasol (Olux) 0.05% foam clobetasol (Olux-E) 0.05% emollient foam diflorasone (Apexicon E) 0.05% emollient cream diflorasone (Psorcon) 0.05% ointment (Vanos) 0.1% cream halobetasol 0.05% foam (LEXETTE)

BRYHALI (halobetasol 0.01% lotion) CLOBEX (clobetasol 0.05% lotion, shampoo) CLODAN (clobetasol 0.05% shampoo) IMPOYZ (clobetasol 0.025% cream IMPEKLO (clobetasol 0.05% lotion, pump) ULTRAVATE (halobetasol) 0.05% lotion

Diagnosis Considered for Coverage: • Relief of the inflammatory and pruritic manifestations of responsive dermatoses

Coverage Criteria:

For Bryhali, halobetasol foam (Lexette), Ultravate lotion: • Being used for plaque psoriasis, and • Inadequate response or intolerable side effect with TWO very high potent topical corticosteroid agents; one of which is either generically available halobetasol cream or ointment.

For clobetasol (Clobex, Clodan, Olux, Olux-E), Impoyz: • For diagnosis listed above, and • Inadequate response or intolerable side effect with ONE preferred generically available clobetasol 0.05% formulation including cream, emollient cream, foam, gel, ointment, and solution.

For diflorasone, fluocinonide: • For diagnosis listed above, and • Inadequate response or intolerance to TWO preferred generically available topical from the very high potency group.

For Impeklo: • For diagnosis listed above, and • Intolerance or contraindication to all preferred topical clobetasol 0.05% (cream, emollient cream, foam, gel, ointment, solution) not expected with Impeklo.

For brand-name formulations: • Meets coverage criteria below for generic formulation, and • Allergic or intolerable side effect to the generic formulation.

Preferred Topical Very High Potency Corticosteroids • augmented dipropionate 0.05% gel, ointment, lotion (Diprolene) • clobetasol 0.05% cream, ointment, solution, gel, cream emollient (Temovate) • halobetasol 0.05% cream, ointment (Ultravate) Coverage Duration: 1 year Effective: 3/03/2021GF