Aclovate, Aristocort/A, Capex, Carmol-HC, Clobex lotion, shampoo, spray, Cloderm, Coraz, Cordran lotion/tape, Cutivate, Cyclocort, Derma-Smoothe FS, Dermatop, Desonate, Desowen, Diprolene/AF, Diprosone, Elocon, Florone/E, Halog, Halog-E, Hytone, Kenalog, Lidex/E, Locoid, Luxiq, Maxiflor, Nuzon, Olux, Olux-E, Olux Olux-E Complete Pack, Pandel, Psorcon/E, Synalar, Temovate, Texacort, Topicort/LP, Tridesilon, Ultravate, Vanos, Verdeso,Westcort and Zytopic are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted. Aetna considers Aclovate, Aristocort/A, Capex, Carmol-HC, Clobex lotion, shampoo, spray, Cloderm, Coraz, Cordran lotion/tape, Cutivate, Cyclocort, Derma-Smoothe FS, Dermatop, Desonate, Desowen, Diprolene/AF, Diprosone, Elocon, Florone/E, Halog, Halog-E, Hytone, Kenalog, Lidex/E, Locoid, Luxiq, Maxiflor, Nuzon, Olux, Olux-E, Olux Olux-E Complete Pack, Pandel, Psorcon/E, Synalar, Temovate, Texacort, Topicort/LP, Tridesilon, Ultravate, Vanos, Verdeso, Westcort and Zytopic to be medically necessary for those members who meet any of the following criteria:
A. A documented:
Contraindication to two covered alternatives indicated for the member's condition OR
Intolerance to two covered alternatives indicated for the member's condition OR
Allergy to two covered alternatives indicated for the member's condition OR
Failure of an adequate trial of two weeks each of two covered alternatives indicated for the member's condition.
Place of Service:
Outpatient
The above policy is based on the following references:
DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
Joly P. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med 2002;346:321-7..
Leung DY, Nicklas RA, Li JT, et al.Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol. 2004;93:S1-21.
Wojnarowska F, Kirtschig G, Highet AS, et al. Guidelines for the management of bullous pemphigoid. Br J Dermatol. 2002;147:214-21.
Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis. J Am Acad Dermatol. 2004;50:391-404.
Hanifin J, Gupta AK, Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Br J Dermatol. 2002;147:528-37.
Green C, Colquitt JL, Kirby J, Davidson P. Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs more frequent use. Br J Dermatol. 2005;152:130-41.
Butani L. Corticosteroid-induced hypersensitivity reactions. Ann Allergy Asthma Immunol. 2002;89:439-45.
Mason J, Mason AR, Cork MJ. Topical preparations for the treatment of psoriasis: a systematic review. Br J Dermatol. 2002;146:351-64.
Franz TJ, Parsell DA, Myers JA, Hannigan JF. Clobetasol propionate foam 0.05%: a novel vehicle with enhanced delivery. Int. J. Dermatol., Jul 2000, 39(7) 521-38.
Stein LF, Sherr A, Solodkina G, et al. Betamethasone valerate foam for treatment of nonscalp psoriasis. J Cutan Med Surg 2001;5:303-7.
Melian EB, Spencer CM, Jarvis B. Clobetasol propionate foam, 0.05%. Am J Clin Dermatol 2001;2:89-92.
Lebwohl M. A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis. Int J Dermatol 2002;41:269-74.
James M. A randomized, double-blind, multicenter trial comparing fluticasone propionate cream, 0.05%, and hydrocortisone-17-butyrate cream, 0.1%, applied twice daily for 4 weeks in the treatment of psoriasis. Cutis 2001;67:2-9.
Green L, Sadoff W. A clinical evaluation of tazarotene 0.1% gel, with and without a high or mid-high-potency corticosteroid, in patients with stable plaque psoriasis. J Cutan Med Surg 2002;6:95-102.
Frequency of application of topical corticosteroids for atopic eczema. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence (NICE); 2004 Aug. 2 p. (Technology appraisal 81). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site.
Clinical and cost-effectiveness of once daily versus more frequent use of same potency topical corticosteroids for atopic eczema: a systematic review and economic evaluation. Assessment report. Southampton (UK): Southampton Health Technology Assessments Centre; 2003 Nov. 142 p. (Technology appraisal 81). Electronic copies: Available in PDF from the National Institute for Health and Clinical Excellence (NICE) Web site.
ARCHIVE VERSION
Property of Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
*C = Covered, copay amount depends on benefits plan
CS = Covered under Specialty Tier
NC = Not Covered Part D drug
PR-B/D = Precertification review criteria to determine coverage as Part B or Part D
PR = Precertification
QL = Quantity Limits
AL = Age Limits
ST = Step-Therapy
‡M EX = Medical Exception
§TOC = Transition of Coverage
*The lists above are subject to change. Not all programs - for example step-therapy, precertification, and quantity limits - are available in all service areas.
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