Us Family Health Plan Pharmacy Program Medical Necessity Form For Topical Antifungals Page 2
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4Medical Necessity Criteria for Topical Antifungals
Ciclopirox (Loprox), oxiconazole (Oxistat), sertaconazole (Ertaczo), and sulconazole (Exelderm) - The non-formulary
cost share may be reduced to the formulary cost share if the patient has tried ALL of the formulary alternatives or has a
clinical reason(s) for not trying ALL of the alternatives, based on the following criteria:
1.
The formulary agent is contraindicated (e.g., due to hypersensitivity).
2.
The formulary agent is not available in the desired formulation.
3.
The formulary agent caused or is likely to cause significant burning, itching, redness or other significant adverse
effects.
4.
An adequate treatment course with the formulary agent resulted in therapeutic failure.
5.
The formulary agent is not effective for the treatment of the specific condition. For example, nystatin is not effective
for the treatment of tinea pedis, corporis, cruris, or versicolor.
Miconazole 0.25% / zinc oxide 15% ( Vusion) - The non-formulary cost share may be reduced to the formulary cost share
if the patient has tried ALL of the formulary alternatives or has a clinical reason(s) for not trying ALL formulary alternatives,
based on the following criteria. Formulary alternatives include higher concentrations of miconazole (2%), clotrimazole, and
nystatin, which are often used in conjunction with zinc oxide ointment, an over-the-counter skin protectant.
1.
The formulary agent is contraindicated (e.g., due to hypersensitivity).
2.
The patient has experienced or is likely to experience significant adverse effects from the formulary agent.
3.
The formulary agent is not available in the desired formulation.
Criteria approved through the DoD P&T Committee process May, 2005 and November, 2006
is the official Web site of the
TRICARE Management Activity,
a component of the
Military Health System
Skyline 5, Suite 810, 5111 Leesburg Pike,
Falls Church, VA 22041-3206
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