Aclovate, Capex, Carmol-HC, Clobex lotion, shampoo, spray, Cloderm, Coraz, Cordran lotion/tape, Cutivate, Derma-Smoothe FS, Dermatop, Desonate, Desowen, Diprolene/AF, Elocon, Halog, Hytone, Kenalog, Lidex/E, Locoid, Luxiq, Nuzon, Olux, Olux-E, Olux Olux-E Complete Pack, Pandel, Psorcon/E, Temovate, Texacort, Topicort/LP, Ultravate, Vanos, Verdeso, and Westcort 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, Capex, Carmol-HC, Clobex lotion, shampoo, spray, Cloderm, Coraz, Cordran lotion/tape, Cutivate, Derma-Smoothe FS, Dermatop, Desonate, Desowen, Diprolene/AF, Elocon, Halog, Hytone, Kenalog, Lidex/E, Locoid, Luxiq, Nuzon, Olux, Olux-E, Olux Olux-E Complete Pack, Pandel, Psorcon/E, Temovate, Texacort, Topicort/LP, Ultravate, Vanos, Verdeso, and Westcort to be medically necessary for those members who meet any of the following criteria:
A. A documented:
Contraindication to two preferred alternatives indicated for the member's condition OR
Intolerance to two preferred alternatives indicated for the member's condition OR
Allergy to two preferred alternatives indicated for the member's condition OR
Failure of an adequate trial of two weeks each of two preferred alternatives indicated for the member's condition.
Place of Service:
Outpatient
The above policy is based on the following references:
1. DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
2. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
3. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
4. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
5. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
6. Clinical Pharmacology [Internet database]. Gold Standard Inc. Tampa, FL. Updated periodically.
7. Lagos BR, Maibach HI. Frequency of application of topical corticosteroids: an overview . Br J Dermatol 1998 Nov;139(5):763-6
8. Ainley-Walker PF, et al. Side to side comparison of topical treatment in atopic dermatitis. Arch Dis Child. 1998 Aug;79(2):149-52
9. Rosenthal P. A challenging question regarding the use of topical corticosteroids for mycosis fungoides.: Arch Dermatol. 1998 Aug;134(8):1033-4
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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