TOPICAL CORTICOSTEROIDS STEP THERAPY Pharmacy Coverage Policy P&T Review Date: 05/27/2015 Policy type: ST UMC Revision Date: 04/09/2015 Program type: Standard Reviewer Initials: NM Specialty: No Effective Date: 06/15/2015 Line of Business: Commercial Brand Name Generic Name GPI Drug Class 90550010004105 Dermatology, Corticosteroids Amcinonide amcinonide 90550010004205 APEXICON E diflorasone diacetate 90550050153705 Dermatology, Corticosteroids CAPEX fluocinolone acetonide 90550055104501 Dermatology, Corticosteroids CLOBEX clobetasol propionate 90550025100910 Dermatology, Corticosteroids 90550025104110 90550025104520 CLODERM clocortolone pivalate 90550030103705 Dermatology, Corticosteroids CLODERM PUMP clocortolone pivalate 90550030103705 Dermatology, Corticosteroids CORDRAN flurandrenolide 90550065003710 Dermatology, Corticosteroids CORDRAN TAPE flurandrenolide 90550065004605 Dermatology, Corticosteroids DERMASORB HC hydrocortisone 90550075656420 Dermatology, Corticosteroids DERMASORB Ta triamcinolone 90550085206420 Dermatology, Corticosteroids DESONATE desonide 90550035004020 Dermatology, Corticosteroids DESOWEN Cream/ Cetaphil Dermatology, Corticosteroids 90550035556420 Lotion desonide DESOWEN Lotion/ Cetaphil Dermatology, Corticosteroids 90550035506420 Cream desonide DESOWEN Ointment/ Dermatology, Corticosteroids 90550035606420 Cetaphil Lotion desonide 90550040003705 Dermatology, Corticosteroids Desoximetasone 90550040004203 desoximetasone 90550040004205 Diflorasone Diacetate diflorasone 90550050103705 Dermatology, Corticosteroids hydrocortisone acetate; Dermatology, Corticosteroids EPIFOAM 90559802403910 pramoxine 90550070003710, Dermatology, Corticosteroids HALOG halcinonide 90550070004205 HALONATE halobetasol propionate 90559902476430 Dermatology, Corticosteroids KENALOG triamcinolone acetate 90550085103400 Dermatology, Corticosteroids LOCOID hydrocortisone butyrate 9055007530**** Dermatology, Corticosteroids LOCOID LIPOCREAM hydrocortisone butyrate 9055007532**** Dermatology, Corticosteroids NUCORT hydrocortisone acetate 90550075104130 Dermatology, Corticosteroids PANDEL Hydrocortisone probutate 90550075273720 Dermatology, Corticosteroids PEDIADERM HC hydrocortisone 90550075706430 Dermatology, Corticosteroids PEDIADERM Ta triamcinolone acetonide 90550085206420 Dermatology, Corticosteroids SCALACORT DK hydrocortisone 90559904356430 Dermatology, Corticosteroids SYNALAR Cream Kit fluocinolone acetonide 90559902406430 Dermatology, Corticosteroids SYNALAR Ointment Kit fluocinolone acetonide 90559902406435 Dermatology, Corticosteroids CATAMARAN LLC. - CONFIDENTIAL AND PROPRIETARY © COPYRIGHT 2014, Catamaran LLC. All rights reserved. Disclaimer: This document is for informational purposes only. Individual pharmacy benefit plan designs and contract language take precedence over coverage policies. Coverage may vary for Medicare or Medicaid plans. Coverage policies are reviewed and updated periodically. Page 1 of 3 TOPICAL CORTICOSTEROIDS Pharmacy Coverage Policy SYNALAR Ts fluocinolone acetonide 90559902396420 Dermatology, Corticosteroids TEXACORT hydrocortisone 90550075002020 Dermatology, Corticosteroids TOPICORT desoximetasone 9055004000**** Dermatology, Corticosteroids TRIANEX triamcinolone acetonide 90550085104207 Dermatology, Corticosteroids ULTRAVATE PAC halobetasol propionate 90559902476410 Dermatology, Corticosteroids 90559902496420, Dermatology, Corticosteroids ULTRAVATE X halobetasol propionate 90559902496440 VANOS fluocinonide 90550060003710 Dermatology, Corticosteroids VERDESO desonide 90550035003920 Dermatology, Corticosteroids CRITERIA FOR COVERAGE/NONCOVERAGE Topical corticosteroids will be considered for coverage under the pharmacy benefit program when the following criteria are met: UM Program Type Targeted Drugs Prerequisite Standard Amcinonide, APEXICON E, CAPEX, CLOBEX, Trial and inadequate response XXSTCRTSN CLODERM, CLODERM PUMP, CORDRAN, or intolerance to TWO CORDRAN SP, CORDRAN TAPE, DERMASORB preferred generic topical HC, DERMASORB TA, DESONATE, corticosteroids DESOWEN/CETAPHIL, desoximetasone, diflorasone diacetate, EPIFOAM, HALOG, halonate, KENALOG, LOCOID, LOCOID LIPOCREAM, NUCORT, PANDEL, PEDIADERM HC, PEDIADERM Ta, SCALACORT KD, SYNALAR, SYNALAR Ts, TEXACORT, TOPICORT, TRIANEX, ULTRAVATE PAC, ULTRAVATE X, VANOS, and VERDESO The program applies to patients of all ages. There is a 180-day look back period for prerequisite drugs, and grandfathering does not apply. If prerequisites are not found within the patient’s prescription claims history, targeted drugs will be considered for coverage under the pharmacy benefit program when the following criteria are met: Patient had a trial and inadequate response or intolerance to at least TWO preferred generic topical corticosteroids Initial Authorization Duration: When the above criteria are met, authorization for use will be granted for 12 months. CATAMARAN LLC. - CONFIDENTIAL AND PROPRIETARY © COPYRIGHT 2014, Catamaran LLC. All rights reserved. Disclaimer: This document is for informational purposes only. Individual pharmacy benefit plan designs and contract language take precedence over coverage policies. Coverage may vary for Medicare or Medicaid plans. Coverage policies are reviewed and updated periodically. Page 2 of 3 TOPICAL CORTICOSTEROIDS Pharmacy Coverage Policy Reauthorization Criteria and Duration: Authorization for continued use shall be reviewed at least every 12 months when the following criteria are met: All of the current coverage policy criteria stated above are met. Topical corticosteroids are considered experimental/investigational for conditions not listed in this coverage policy section. CATAMARAN LLC. - CONFIDENTIAL AND PROPRIETARY © COPYRIGHT 2014, Catamaran LLC. All rights reserved. Disclaimer: This document is for informational purposes only. Individual pharmacy benefit plan designs and contract language take precedence over coverage policies. Coverage may vary for Medicare or Medicaid plans. Coverage policies are reviewed and updated periodically. Page 3 of 3 .