Topical Antifungal Step Therapy Pharmacy Coverage Policy P&T Review Date: 07/22/2015 Policy type: ST UMC Revision Date: 06/18/2015 Program type: Standard, Value Reviewer Initials: LH Specialty: No Effective Date: 08/15/2015 Line of Business: Commercial Brand Name Generic Name GPIs Drug Class ECOZA econazole nitrate topical foam 90154035103910 Antifungal LUZU luliconazole cream 901540480037** Antifungal NAFTIN naftifine hydrochloride cream and gel 9015007800**** Antifungal MENTAX butenafine hydrochloride cream 9015002610**** Antifungal ERTACZO sertaconazole nitrate cream 9015407010**** Antifungal OXISTAT oxiconazole cream and lotion 9015406500**** Antifungal EXELDERM sulconazole cream and solution 9015407500**** Antifungal XOLEGEL ketoconazole gel 901540450040** Antifungal CRITERIA FOR COVERAGE/NONCOVERAGE UM Program Type Targeted Drugs Prerequisite Standard Trial with a least two of the XXSTTAFSN following generic or over the counter topical antifungal ECOZA, LUZU, NAFTIN, naftifine, therapies: ketoconazole, MENTAX, ERTACZO, OXISTAT, miconazole, terbinafine, econazole EXELDERM and XOLEGEL cream, clotrimazole, tolnaftate, butenafine (Lotrimin Ultra)or ciclopirox Value Trial with a least two of the XXSTTAFVN following generic or over the counter topical antifungal ECOZA, LUZU, naftifine, MENTAX, therapies: ketoconazole, ERTACZO, OXISTAT, EXELDERM and miconazole, terbinafine, econazole XOLEGEL cream, clotrimazole, tolnaftate, butenafine (Lotrimin Ultra)or ciclopirox The program applies to patients of all ages, there is a 180 day look back period for prerequisite drugs, and grandfathering does not apply. 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 2 Topical Antifungal Step Therapy Pharmacy Coverage Policy 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 has a diagnosis of tinea pedis (athlete’s foot), tinea cruris (jock itch), tinea corporis (ring worm), tinea versicolor or seborrheic dermatitis AND o Patient has had a trial and failure, intolerance or hypersensitivity to at least two listed generic or over the counter topical antifungal therapies: Ketoconazole Miconazole Terbinafine Econazole cream Clotrimazole Tolnaftate Butenafine (Lotrimin Ultra) Ciclopirox Reauthorization Criteria and Duration: Authorizations shall be granted for 2 months when coverage criteria are met. 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 2 .