TOPICAL CORTICOSTEROIDS Alcovate Cream, Ointment 0.05%

Home , Alclometasone, Amcinonide, Betamethasone, Clobetasol, Clobetasol propionate, Clocortolone

Locoid Cream, Lipocream, Lotion, Ointment, Alcovate Cream, Ointment 0.05% Solution 0.1% (alclometasone dipropionate) (hydrocortisone butyrate) Apexicon E Cream 0.05% Luxiq Foam 0.12% (diflorasone diacetate) (betamethasone valerate) Ala Scalp Lotion 2% Micort-HC Cream 2.5% (hydrocortisone) (hydrocortisone acetate) Capex Shampoo 0.01% Nolix Cream, Lotion 0.05% (fluocinolone acetonide) (flurandrenolide) Olux Foam 0.05% Cloderm Cream 0.10% Olux E Emulsion Foam 0.05% (clocortolone pivalate) (clobetasol propionate) Clobex Lotion, Shampoo, Spray 0.05% Pandel Cream 0.1% Clodan Shampoo 0.05% (hydrocortisone probutate) (clobetasol propionate) Cordran Cream 0.025% Cordran Cream, Lotion, Ointment 0.05% Psorcon Cream, Ointment 0.05% Cordran Tape 4mcg (diflorasone) (flurandrenolide) Cormax Solution 0.05% Sernivo Spray 0.05% (clobetasol propionate) (betamethasone dipropionate) Cutivate Cream, Lotion 0.05% Synalar Cream, Ointment, Solution 0.01% Cutivate Ointment 0.005% Synalar Cream, Ointment 0.025% (fluticasone propionate) (fluocinolone acetonide) Temovate-E Cream 0.05% Cyclocort Cream, lotion, Ointment 0.1% Temovate Cream, Gel, Ointment, Solution (amcinonide) 0.05% (clobetasol propionate) Derma-smooth /FS body oil 0.01% Texacort Solution 2.5% Derma-smooth /FS scalp oil 0.01% (hydrocortisone) (fluocinolone acetonide) Topicort Cream, Gel, Ointment, Spray Dermatop Cream, Ointment 0.1% 0.05% 0.25% (prednicarbate) (desoximetasone) Triamcinolone Cream, Lotion, Ointment, Desonate Gel 0.05% Spray 0.025%, 0.05%, 0.1%, 0.5% Desonide Cream Lotion, Ointment 0.05% Triderm Cream 0.1%, 0.5% Desowen Lotion 0.05% Kenalog aerosol spray 0.147 mg/ml (desonide) (triamcinolone acetonide) Diprosone Cream, Lotion, Ointment 0.05% Tridesilon Cream 0.05% Diprolene AF Cream, Gel, Lotion, Verdeso Foam 0.05% Ointment 0.05% (desonide) (betamethasone dipropionate) Elocon Cream, Ointment, Solution 0.1% Trianex* Ointment 0.05% (mometasone furoate) (triamcinolone acetonide)

Topical Corticosteroids FEP Clinical Criteria

Halog Cream, Ointment, Solution 0.1% Ultravate Cream, Lotion, Ointment 0.05% (halcinonide) (halobetasol propionate) Hydrocortisone Cream, Lotion, Ointment Wescort Cream, Ointment 0.2% 1%, 2.5% (hydrocortisone valerate) Impeklo Lotion 0.05% Valisone Cream, Lotion, Ointment 0.01% (clobetasol propionate) (betamethasone valerate) Vanos* Cream, Gel, Ointment, Solution Impoyz Cream 0.025% 0.1% (clobetasol propionate) (fluocinonide) Lidex E Cream 0.05% Verdeso Foam 0.05% Lidex Gel, Ointment, Solution, Cream (desonide) 0.05% (fluocinonide)

*Prior authorization for certain non-covered formulations applies only to formulary exceptions ______

Pre - PA Allowance

Quantity

ALCLOMETASONE 3 MONTH Strength UOM Potency DIPROPIONATE LIMIT ALCLOMETASONE Low to 0.05% GM 460 CREAM Medium ALCLOMETASONE Low to 0.05% GM 460 OINTMENT Medium 3 MONTH AMCINONIDE Strength UOM Potency LIMIT AMCINONIDE 0.1% GM High 460 CREAM AMCINONIDE 0.1% ML High 460 LOTION AMCINONIDE 0.1% GM High 460 OINTMENT BETAMETHASONE 3 MONTH Strength UOM Potency DIPROPIONATE LIMIT SERNIVO 0.05% ML Medium 460 SPRAY BETAMETHASONE DIPROPIONATE 0.05% GM Medium 460 CREAM BETAMETHASONE DIPROPIONATE 0.05% ML Medium 460 LOTION BETAMETHASONE DIPROPIONATE Very 0.05% GM 460 OINTMENT high DIPROLENE AF 0.05% GM AUGMENTED CREAM High 460 BETAMETHASONE DIPROPIONATE 0.05% GM AUGMENTED CREAM BETAMETAMETHASONE DIPROPIONATE Very AUGMENTED 0.05% GM 460 high GEL

Topical Corticosteroids FEP Clinical Criteria BETAMETAMETHASONE DIPROPIONATE Very AUGMENTED 0.05% ML 460 high LOTION DIPROLENE 0.05% GM AUGMENTED OINTMENT Very 460 BETAMETHASONE DIPROPIONATE high 0.05% GM AUGMENTED OINTMENT BETAMETHASONE 3 MONTH Strength UOM Potency VALERATE LIMIT BETAMETHASONE VALERATE 0.1% GM Medium 460 CREAM LUXIQ 0.12% GM AEROSOL FOAM Medium 460 BETAMETHASONE VALERATE 0.12% GM AEROSOL FOAM BETAMETHASONE VALERATE 0.1% ML Medium 460 LOTION BETAMETHASONE VALERATE 0.1% GM Medium 460 OINTMENT CLOBETASOL 3 MONTH Strength UOM Potency PROPIONATE LIMIT CLOBEX 0.05% ML SPRAY Very 460 CLOBETASOL high 0.05% ML SPRAY CORMAX 0.05% ML SOLUTION High 460 TEMOVATE 0.05% ML SOLUTION IMPOYZ 0.025% GM High 460 CREAM TEMOVATE 0.05% GM CREAM Very 460 CLOBETASOL high 0.05% GM CREAM OLUX 0.05% GM AEROSOL FOAM Very 460 CLOBETASOL high 0.05% GM AEROSOL FOAM CLOBETASOL Very 0.05% GM 460 GEL high CLOBEX 0.05% ML LOTION Very 460 CLOBETASOL high 0.05% ML LOTION TEMOVATE 0.05% GM OINTMENT Very 460 CLOBETASOL high 0.05% GM OINTMENT CLOBEX Very 0.05% ML 460 SHAMPOO high

Topical Corticosteroids FEP Clinical Criteria CLODAN 0.05% ML SHAMPOO CLOBETASOL E Very 0.05% GM 460 EMOLLIENT CREAM high OLUX-E 0.05% GM AEROSOL EMULSION FOAM Very 460 CLOBETASOL high 0.05% GM AEROSOL EMULSION FOAM Very IMPEKLO LOTION 0.05% GM 460 high CLOCORTOLONE 3 MONTH Strength UOM Potency PIVALATE LIMIT CLODERM 0.10% GM CREAM Medium 460 CLOCORTOLONE 0.10% GM CREAM 3 MONTH DESONIDE Strength UOM Potency LIMIT DESOWEN 0.05% GM Low to CREAM Medium DESONIDE 0.05% GM CREAM 460 TRIDESILON 0.05% GM CREAM Low DESONIDE 0.05% GM CREAM VERDESO 0.05% GM Low 460 AEROSOL FOAM DESONATE 0.05% GM Low 460 GEL DESOWEN 0.05% ML LOTION Low to 460 DESONIDE Medium 0.05% ML LOTION DESONIDE 0.05% GM Low 460 OINTMENT 3 MONTH DESOXIMETASONE Strength UOM Potency LIMIT TOPICORT 0.25% ML High to SPRAY Very 460 DESOXIMETASONE 0.25% ML high SPRAY TOPICORT 0.05% GM CREAM Medium 460 DESOXIMETASONE 0.05% GM CREAM TOPICORT 0.25% GM CREAM High 460 DESOXIMETASONE 0.25% GM CREAM TOPICORT 0.05% GM High 460 GEL

Topical Corticosteroids FEP Clinical Criteria DESOXIMETASONE 0.05% GM GEL TOPICORT 0.05% GM OINTMENT High 460 DESOXIMETASONE 0.05% GM OINTMENT TOPICORT 0.25% GM OINTMENT High 460 DESOXIMETASONE 0.25% GM OINTMENT DIFLORASONE 3 MONTH Strength UOM Potency DIACETATE LIMIT PSORCON 0.05% GM CREAM High 460 DIFLORASONE 0.05% GM CREAM DIFLORASONE Very 0.05% GM 460 OINTMENT high APEXICON E 0.05% GM High 460 CREAM FLUOCINOLONE 3 MONTH Strength UOM Potency ACETONIDE LIMIT DERMA-SMOOTH /FS 0.01% ML BODY OIL Low to 460 FLUOCINOLONE medium 0.01% ML BODY OIL DERMA-SMOOTH /FS 0.01% ML SCALP OIL Low to 460 FLUOCINOLONE medium 0.01% ML SCALP OIL SYNALAR 0.01% ML SOLUTION Low 460 FLUOCINOLONE 0.01% ML SOLUTION FLUOCINOLONE 0.01% GM Low 460 CREAM SYNALAR 0.025% GM CREAM Medium 460 FLUOCINOLONE 0.025% GM CREAM SYNALAR 0.025% GM OINTMENT Medium 460 FLUOCINOLONE 0.025% GM OINTMENT CAPEX Low to 0.01% ML 460 SHAMPOO Medium 3 MONTH FLUOCINONIDE Strength UOM Potency LIMIT FLUOCINONIDE 0.05% ML High 460 SOLUTION FLUOCINONIDE 0.05% GM High 460 CREAM

Topical Corticosteroids FEP Clinical Criteria FLUOCINONIDE 0.05% GM High 460 GEL FLUOCINONIDE 0.05% GM High 460 OINTMENT FLUOCINONIDE-E 0.05% GM High 460 EMULSIFIED CREAM FLUOCINONIDE Very 0.1% GM 460 CREAM high FLUOCINONIDE Very 0.1% GM 460 GEL high FLUOCINONIDE Very 0.1% GM 460 OINTMENT high FLUOCINONIDE Very 0.1% GM 460 SOLUTION high 3 MONTH FLURANDRENOLIDE Strength UOM Potency LIMIT CORDRAN 0.025% GM High 460 CREAM CORDRAN 0.05% GM CREAM High 460 NOLIX 0.05% GM CREAM CORDRAN 0.05% ML LOTION High 460 NOLIX 0.05% ML LOTION CORDRAN 0.05% GM OINTMENT High 460 FLURANDRENOLIDE 0.05% GM OINTMENT CORDRAN 4 MCG EA High 2 Rolls TAPE FLUTICASONE 3 MONTH Strength UOM Potency PROPIONATE LIMIT FLUTICASONE 0.05% GM Medium 460 CREAM CUTIVATE 0.05% ML LOTION Medium 460 FLUTICASONE 0.05% ML LOTION FLUTICASONE 0.005% GM Medium 460 OINTMENT 3 MONTH HALCINONIDE Strength UOM Potency LIMIT HALOG 0.1% GM High 460 CREAM HALOG 0.1% GM High 460 OINTMENT HALOG 0.1% ML High 460 SOLUTION HALOBETASOL 3 MONTH Strength UOM Potency PROPIONATE LIMIT

Topical Corticosteroids FEP Clinical Criteria ULTRAVATE 0.05% GM CREAM HALOBETASOL Very 0.05% GM 460 CREAM high HALOBETASOL 0.05% GM AEROSOL FOAM ULTRAVATE Very 0.05% ML 460 LOTION high ULTRAVATE 0.05% GM OINTMENT Very 460 HALOBETASOL high 0.05% GM OINTMENT 3 MONTH HYDROCORTISONE Strength UOM Potency LIMIT TEXACORT 2.5% ML Low 460 SOLUTION HYDROCORTISONE 1% GM Low 460 CREAM HYDROCORTISONE 2.5% GM Low 460 CREAM ALA SCALP 2% ML Low 460 LOTION HYDROCORTISONE 2.5% ML Low 460 LOTION HYDROCORTISONE 1% GM Low 460 OINTMENT HYDROCORTISONE 2.5% GM Low 460 OINTMENT HYDROCORTISONE 3 MONTH Strength UOM Potency ACETATE LIMIT MICORT-HC 2.5% GM Low 460 CREAM HYDROCORTISONE 3 MONTH Strength UOM Potency VALERATE LIMIT HYDROCORTISONE VALERATE 0.2% GM Medium 460 CREAM WESTCORT 0.2% GM OINTMENT Medium 460 HYDROCORTISONE VALERATE 0.2% GM OINTMENT 3 MONTH HYDROCORTISONE PROBUTATE Strength UOM Potency LIMIT PANDEL 0.1% GM Medium 460 CREAM HYDROCORTISONE 3 MONTH Strength UOM Potency BUTYRATE LIMIT LOCOID 0.1% ML SOLUTION Medium 460 HYDROCORTISONE BUTYRATE 0.10% ML SOLUTION LOCOID 0.1% GM Medium 460 CREAM

Topical Corticosteroids FEP Clinical Criteria HYDROCORTISONE BUTYRATE 0.1% GM CREAM LOCOID 0.1% ML LOTION Medium 460 HYDROCORTISONE 0.1% ML LOTION LOCOID 0.1% GM OINTMENT Medium 460 HYDROCORTISONE BUTYRATE 0.1% GM OINTMENT LOCOID 0.1% GM HYDROPHILIC LIPOCREAM Medium 460 HYDROCORTISONE BUTYRATE 0.10% GM HYDROPHILIC LIPOCREAM MOMETASONE 3 MONTH Strength UOM Potency FUROATE LIMIT MOMETASONE 0.1% ML Medium 460 SOLUTION ELOCON 0.1% GM CREAM Medium 460 MOMETASONE 0.1% GM CREAM ELOCON 0.1% GM OINTMENT Medium 460 MOMETASONE 0.1% GM OINTMENT 3 MONTH PREDNICARBATE Strength UOM Potency LIMIT PREDNICARBATE 0.1% GM Medium 460 CREAM DERMATOP 0.1% GM OINTMENT Medium 460 PREDNICARBATE 0.1% GM OINTMENT TRIAMCINOLONE 3 MONTH Strength UOM Potency ACETONIDE LIMIT KENALOG SPRAY GM AEROSOL SPRAY High 460 TRIAMCINOLONE SPRAY GM AEROSOL SPRAY TRIAMCINOLONE 0.025% GM Medium 460 CREAM TRIAMCINOLONE 0.1% GM Medium 460 CREAM TRIAMCINOLONE 0.5% GM High 460 CREAM TRIAMCINOLONE 0.025% ML Medium 460 LOTION TRIAMCINOLONE 0.1% ML Medium 460 LOTION TRIAMCINOLONE 0.025% GM Medium 460 OINTMENT

Topical Corticosteroids FEP Clinical Criteria TRIANEX 0.05% GM Medium None OINTMENT TRIAMCINOLONE 0.1% GM Medium 460 OINTMENT TRIAMCINOLONE 0.5% GM High 460 OINTMENT ➢ Pre-PA quantity limit allows for the American Academy of Dermatology (AAD) recommended dosage. ➢ Patients are limited to 460 units per 90 days of any combination of the above (excluding Cordran tape) for Pre- PA allowance. If the quantity requested exceeds the cumulative Pre-PA quantity limit, the claim will reject with a message indicating that a prior authorization is required.

Prior-Approval Requirements

Diagnosis

Patient must have the following:

1. FDA-approved indication supporting the use of topical product 2. Requested medication is NOT being used in a footbath

Prior - Approval Limits Quantity ALCLOMETASONE Quantity per 90 Strength UOM Potency DIPROPIONATE Days ALCLOMETASONE Low to 0.05% GM 720 CREAM Medium ALCLOMETASONE Low to 0.05% GM 720 OINTMENT Medium Quantity per 90 AMCINONIDE Strength UOM Potency Days AMCINONIDE 0.1% GM High 720 CREAM AMCINONIDE High 0.1% ML 720 LOTION AMCINONIDE High 0.1% GM 720 OINTMENT BETAMETHASONE Quantity per 90 Strength UOM Potency DIPROPIONATE Days SERNIVO 0.05% ML Medium 720 SPRAY BETAMETHASONE DIPROPIONATE 0.05% GM Medium 720 CREAM BETAMETHASONE DIPROPIONATE 0.05% ML Medium 720 LOTION BETAMETHASONE Very DIPROPIONATE 0.05% GM 720 high OINTMENT

Topical Corticosteroids FEP Clinical Criteria DIPROLENE AF 0.05% GM AUGMENTED CREAM BETAMETHASONE High 720 DIPROPIONATE 0.05% GM AUGMENTED CREAM BETAMETAMETHASONE DIPROPIONATE Very 0.05% GM 720 AUGMENTED high GEL BETAMETAMETHASONE DIPROPIONATE Very 0.05% ML 720 AUGMENTED high LOTION DIPROLENE 0.05% GM AUGMENTED OINTMENT Very BETAMETHASONE 720 high DIPROPIONATE 0.05% GM AUGMENTED OINTMENT BETAMETHASONE Quantity per 90 Strength UOM Potency VALERATE Days BETAMETHASONE VALERATE 0.1% GM Medium 720 CREAM LUXIQ 0.12% GM AEROSOL FOAM BETAMETHASONE Medium 720 VALERATE 0.12% GM AEROSOL FOAM BETAMETHASONE VALERATE 0.1% ML Medium 720 LOTION BETAMETHASONE VALERATE 0.1% GM Medium 720 OINTMENT CLOBETASOL Quantity per 90 Strength UOM Potency PROPIONATE Days CLOBEX 0.05% ML SPRAY Very 720 CLOBETASOL high 0.05% ML SPRAY CORMAX High 0.05% ML SOLUTION 720 TEMOVATE 0.05% ML SOLUTION IMPOYZ High 0.025% GM 720 CREAM TEMOVATE 0.05% GM CREAM Very 720 CLOBETASOL high 0.05% GM CREAM OLUX Very 0.05% GM 720 AEROSOL FOAM high

Topical Corticosteroids FEP Clinical Criteria CLOBETASOL 0.05% GM AEROSOL FOAM CLOBETASOL Very 0.05% GM 720 GEL high CLOBEX 0.05% ML LOTION Very 720 CLOBETASOL high 0.05% ML LOTION TEMOVATE 0.05% GM OINTMENT Very 720 CLOBETASOL high 0.05% GM OINTMENT CLOBEX 0.05% ML SHAMPOO Very 720 CLODAN high 0.05% ML SHAMPOO CLOBETASOL E Very 0.05% GM 720 EMOLLIENT CREAM high OLUX-E AEROSOL EMULSION 0.05% GM FOAM Very 720 CLOBETASOL high AEROSOL EMULSION 0.05% GM FOAM Very IMPEKLO LOTION 0.05% GM 720 high CLOCORTOLONE Quantity per 90 Strength UOM Potency PIVALATE Days CLODERM 0.10% GM CREAM Medium 720 CLOCORTOLONE 0.10% GM CREAM Quantity per 90 DESONIDE Strength UOM Potency Days DESOWEN 0.05% GM CREAM Low to DESONIDE Medium 0.05% GM CREAM 720 TRIDESILON 0.05% GM CREAM Low DESONIDE 0.05% GM CREAM VERDESO 0.05% GM Low 720 AEROSOL FOAM DESONATE 0.05% GM Low 720 GEL DESOWEN 0.05% ML LOTION Low to 720 DESONIDE Medium 0.05% ML LOTION DESONIDE 0.05% GM Low 720 OINTMENT

Topical Corticosteroids FEP Clinical Criteria Quantity per 90 DESOXIMETASONE Strength UOM Potency Days TOPICORT 0.25% ML High to SPRAY very 720 DESOXIMETASONE 0.25% ML high SPRAY TOPICORT 0.05% GM CREAM Medium 720 DESOXIMETASONE 0.05% GM CREAM TOPICORT High 0.25% GM CREAM 720 DESOXIMETASONE 0.25% GM CREAM TOPICORT High 0.05% GM GEL 720 DESOXIMETASONE 0.05% GM GEL TOPICORT High 0.05% GM OINTMENT 720 DESOXIMETASONE 0.05% GM OINTMENT TOPICORT High 0.25% GM OINTMENT 720 DESOXIMETASONE 0.25% GM OINTMENT DIFLORASONE Quantity per 90 Strength UOM Potency DIACETATE Days PSORCON 0.05% GM CREAM High 720 DIFLORASONE 0.05% GM CREAM DIFLORASONE Very 0.05% GM 720 OINTMENT high APEXICON E 0.05% GM High 720 CREAM FLUOCINOLONE Quantity per 90 Strength UOM Potency ACETONIDE Days DERMA-SMOOTH /FS 0.01% ML BODY OIL Low to 720 FLUOCINOLONE medium 0.01% ML BODY OIL DERMA-SMOOTH /FS 0.01% ML SCALP OIL Low to 720 FLUOCINOLONE medium 0.01% ML SCALP OIL SYNALAR 0.01% ML SOLUTION Low 720 FLUOCINOLONE 0.01% ML SOLUTION FLUOCINOLONE 0.01% GM Low 720 CREAM

Topical Corticosteroids FEP Clinical Criteria SYNALAR 0.025% GM CREAM Medium 720 FLUOCINOLONE 0.025% GM CREAM SYNALAR 0.025% GM OINTMENT Medium 720 FLUOCINOLONE 0.025% GM OINTMENT CAPEX Low to 0.01% ML 720 SHAMPOO Medium Quantity per 90 FLUOCINONIDE Strength UOM Potency Days FLUOCINONIDE High 0.05% ML 720 SOLUTION FLUOCINONIDE High 0.05% GM 720 CREAM FLUOCINONIDE High 0.05% GM 720 GEL FLUOCINONIDE High 0.05% GM 720 OINTMENT FLUOCINONIDE-E High 0.05% GM 720 EMULSIFIED CREAM FLUOCINONIDE Very 0.1% GM 720 CREAM high Very Refer to the high Formulary VANOS CREAM 0.1% GM Exception Table Below FLUOCINONIDE Very 0.1% GM 720 GEL high FLUOCINONIDE Very 0.1% GM 720 OINTMENT high FLUOCINONIDE Very 0.1% GM 720 SOLUTION high Quantity per 90 FLURANDRENOLIDE Strength UOM Potency Days CORDRAN High 0.025% GM 720 CREAM CORDRAN High 0.05% GM CREAM 720 NOLIX 0.05% GM CREAM CORDRAN High 0.05% ML LOTION 720 NOLIX 0.05% ML LOTION CORDRAN High 0.05% GM OINTMENT 720 FLURANDRENOLIDE 0.05% GM OINTMENT CORDRAN High 4 MCG EA 4 Rolls TAPE

Topical Corticosteroids FEP Clinical Criteria FLUTICASONE Quantity per 90 Strength UOM Potency PROPIONATE Days FLUTICASONE Medium 0.05% GM 720 CREAM CUTIVATE Medium 0.05% ML LOTION 720 FLUTICASONE 0.05% ML LOTION FLUTICASONE Medium 0.005% GM 720 OINTMENT Quantity per 90 HALCINONIDE Strength UOM Potency Days HALOG High 0.1% GM 720 CREAM HALOG High 0.1% GM 720 OINTMENT HALOG High 0.1% ML 720 SOLUTION HALOBETASOL Quantity per 90 Strength UOM Potency PROPIONATE Days ULTRAVATE 0.05% GM CREAM HALOBETASOL Very 0.05% GM 720 CREAM high HALOBETASOL 0.05% GM AEROSOL FOAM ULTRAVATE Very 0.05% ML 720 LOTION high ULTRAVATE 0.05% GM OINTMENT Very 720 HALOBETASOL high 0.05% GM OINTMENT Quantity per 90 HYDROCORTISONE Strength UOM Potency Days TEXACORT 2.5% ML Low 720 SOLUTION HYDROCORTISONE 1% GM Low 720 CREAM HYDROCORTISONE 2.5% GM Low 720 CREAM ALA SCALP 2% ML Low 720 LOTION HYDROCORTISONE 2.5% ML Low 720 LOTION HYDROCORTISONE 1% GM Low 720 OINTMENT HYDROCORTISONE 2.5% GM Low 720 OINTMENT HYDROCORTISONE Quantity per 90 Strength UOM Potency ACETATE Days MICORT-HC 2.5% GM Low 720 CREAM

Topical Corticosteroids FEP Clinical Criteria HYDROCORTISONE Quantity per 90 Strength UOM Potency VALERATE Days HYDROCORTISONE Medium VALERATE 0.2% GM 720 CREAM WESTCORT Medium 0.2% GM OINTMENT HYDROCORTISONE 720 VALERATE 0.2% GM OINTMENT HYDROCORTISONE Quantity per 90 Strength UOM Potency PROBUTATE Days PANDEL 0.1% GM Medium 720 CREAM HYDROCORTISONE Quantity per 90 Strength UOM Potency BUTYRATE Days LOCOID Medium 0.1% ML SOLUTION HYDROCORTISONE 720 BUTYRATE 0.10% ML SOLUTION LOCOID Medium 0.1% GM CREAM HYDROCORTISONE 720 BUTYRATE 0.1% GM CREAM LOCOID Medium 0.1% ML LOTION 720 HYDROCORTISONE 0.1% ML LOTION LOCOID Medium 0.1% GM OINTMENT HYDROCORTISONE 720 BUTYRATE 0.1% GM OINTMENT LOCOID Medium HYDROPHILIC 0.1% GM LIPOCREAM HYDROCORTISONE 720 BUTYRATE 0.10% GM HYDROPHILIC LIPOCREAM MOMETASONE Quantity per 90 Strength UOM Potency FUROATE Days MOMETASONE Medium 0.1% ML 720 SOLUTION ELOCON Medium 0.1% GM CREAM 720 MOMETASONE 0.1% GM CREAM ELOCON Medium 0.1% GM 720 OINTMENT

Topical Corticosteroids FEP Clinical Criteria MOMETASONE 0.1% GM OINTMENT Quantity per 90 PREDNICARBATE Strength UOM Potency Days PREDNICARBATE Medium 0.1% GM 720 CREAM DERMATOP Medium 0.1% GM OINTMENT 720 PREDNICARBATE 0.1% GM OINTMENT TRIAMCINOLONE Quantity per 90 Strength UOM Potency ACETONIDE Days KENALOG SPRAY GM AEROSOL SPRAY High 720 TRIAMCINOLONE SPRAY GM AEROSOL SPRAY TRIAMCINOLONE Medium 0.025% GM 720 CREAM TRIAMCINOLONE Medium 0.1% GM 720 CREAM TRIAMCINOLONE 0.5% GM High 720 CREAM TRIAMCINOLONE 0.025% ML Medium 720 LOTION TRIAMCINOLONE Medium 0.1% ML 720 LOTION TRIAMCINOLONE Medium 0.025% GM 720 OINTMENT Medium Refer to the TRIANEX Formulary 0.05% GM OINTMENT Exception Table Below TRIAMCINOLONE 0.1% GM Medium 720 OINTMENT TRIAMCINOLONE 0.5% GM High 720 OINTMENT ➢ The Prior-Approval quantity limit is based on average AAD estimation for up to 18% BSA. ➢ Patients are limited to 720 units per 90 days of any combination of the above (excluding Cordran tape and formulary exceptions) for Prior-Approval.

Quantity Medication Strength UOM Potency per 90 with approved formulary exception only Days TRIANEX 0.05% GM Medium 460 OINTMENT VANOS 0.1% GM Very high 460 (FLUOCINONIDE CREAM)

Topical Corticosteroids FEP Clinical Criteria ➢ The Prior-Approval quantity limit with approved formulary exception allows for the American Academy of Dermatology (AAD) recommended dosage.

Duration 6 months

Prior – Approval Renewal Requirements Same as above

Prior–Approval Renewal Limits Same as above

Topical Corticosteroids FEP Clinical Criteria