Prior Authorization Guideline - OptumRx

optumrx.com

Prior Authorization Guideline - OptumRx

Low potency Hytone ® , Cortaid ® Hydrocortisone acetate

Aclovate ®

Alclometasone

DesOwen ® , Tridelison ® Desonide

Kenalog ®

Triamcinolone acetonide

Synalar ®

Fluocinolone acetonide

Valisone ®

Betamethasone valerate

Medium potency Cordran ® Flurandrenolide

Cutivate ®

Fluticasone

Diprosone ®

Betamethasone dipropionate

Elocon ®

Mometasone

Kenalog ®

Triamcinolone acetonide

Locoid ®

Hydrocortisone butyrate

Synalar ®

Fluocinolone acetonide

Topicort ® LP

Desoximetasone

Westcort ®

Hydrocortisone valerate

High Potency Cyclocort ® Amcinonide

Diprolene ® , Diprolene ® AF Augmented betamethasone

dipropionate

Diprosone ®

Betamethasone dipropionate

Halog ®

Halcinonide

Kenalog ®

Triamcinolone acetonide

Lidex ®

Fluocinonide

Topicort ®

Desoximetasone

Psorcon ®

Diflorasone diacetate

Temovate ®

Clobetasol propionate

Ultravate ®

Halobetasol propionate

Vanos ®

Fluocinonide

IV.

CONTRAINDICATIONS AND WARNINGS

A. Contraindications

1. Hypersensitivity reaction

B. Warnings

Elidel is contraindicated in patients with a history of hypersensitivity to pimecrolimus or

any of the components of the cream. 1

Protopic is contraindicated in patients with history of hypersensitivity to tacrolimus or

any other component of the preparation. 2

1. Carcinogenesis 1-3

The FDA issued a public health advisory to inform healthcare professionals and patients

about a potential cancer risk from use of Protopic (tacrolimus) and Elidel

(pimecrolimus). 3 This concern is based on information from animal studies, case reports

in a small number of patients, and knowledge of how drugs in this class work. It may take

human studies of ten years or longer to determine if use of Protopic or Elidel is linked to

cancer. In the meantime, this risk is uncertain, and FDA advises Protopic and Elidel

should be used only as labeled, for patients after other prescription treatments have failed

to work or cannot be tolerated.

2. Others

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