Subject: Seborrhea Agents

Status	Drug	PR	PR-QL	PR-AL	ST	M EX‡
P	ketoconazole
P	selenium sulfide shampoo
P	sulfacetamide sodium-urea pad
P	sulfacetamide sodium
P	Loprox® shampoo  (ciclopirox)
NP	Nizoral®  (ketoconazole)
FE	Capitrol®  (chloroxine)					X
FE	Extina®  (ketoconazole 2% foam)					X
FE	Ovace wash®  (sulfacetamide sodium)					X
FE	Rosula® NS  (sulfacetamide sodium-urea pad)					X
FE	Sebizon®  (sulfacetamide sodium)					X
FE	Tersi foam™  (selenium sulfide )					X
FE	Xolegel gel ®  (ketoconazole gel)					X
FE	Xolegel duo kit®  (ketoconazole gel 2% and pyrithione zinc shampoo 1%)					X

Policy:

1. Medical Exception Criteria

Capitrol, Extina, Ovace, Rosula NS,  Sebizon, Tersi foam and Xologel gel/kit are currently listed on the Aetna Formulary Exclusions List.* Therefore, Capitrol , Extina, Ovace, Rosula NS, Sebizon  Tersi foam and Xolegel gel/kit 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 Capitrol, Extina, Ovace and Sebizon,Tersi foam  Xolegel gel/kit be medically necessary for those members who meet any of the following:

A.  A documented:

• Contraindication to one preferred alternative indicated for the member's condition OR
• Intolerance to one preferred alternative indicated for the member's condition OR
• Allergy to one preferred alternative indicated for the member's condition OR
• Failure of an adequate trial of two weeks of one preferred alternative indicated for the member's condition.
  

Place of Service:

Outpatient

The above policy is based on the following references:

1. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. 2006.
2. USP DI® Drug Information For The Health Care Professional - 26th Ed. (online from www.statref.com) Thomson Micromedex, Greenwood Village, CO. 2006.
3. AHFS Drug Information® with AHFSfirstReleases®. (online from www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. 2006.
4. DRUGDEX^® System: Klasco RK (Ed):DRUGDEX^® System. Online edition. Thomson Micromedex, Greenwood Village, CO.
5. PDR^® Electronic Library, Thomson Micromedex, Greenwood Village, Colorado (Edition expires 2006).
6. Schwartz RA, Janusz CA, Janniger CK. Seborrheic dermatitis: an overview. Am Fam Physician. 2006 Jul 1;74(1):125-30.
7. Xolegel gel /kit product information accessed at http://xolegel.com/hcp/duo.php
8. Extina product information accessed at: http://extina.com/

 

Copyright 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.

September 26, 2007