Prior Auth Protocol

FDA Approved Indications:

Topical treatment of plaque psoriasis in patients eighteen years of age and older.

Health Net Approved Indications and Usage Guidelines:

Diagnosis of plaque psoriasis

AND

Failure or clinically significant adverse effects to generic halobetasol propionate and generic clobetasol propionate

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.

General Information:

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Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
halobetasol propionate 0.05% cream/ointment (Ultravate)	Apply a thin layer to the affected skin QD to BID, rub in gently and completely. Treatment should be limited to two weeks.	50 g/week
clobetasol propionate 0.05% cream/foam/gel/lotion/ointment/shampoo/spray (Clobex, Clodan, Cormax, Embeline, Olux-E, Olux, Tenorvate)	Plaque Psoriasis: Apply a thin layer to the affected skin BID, rub in gently and completely. Treatment for mild to moderate plaque psoriasis should be limited to 2 weeks, moderate to severe treatment up to 4 weeks.	50 g/week

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Ultravate	Apply a thin layer to the affected skin BID for up to two weeks. Rub in gently Total dosage should not exceed 50 g (50 mL) per week.	Length of Benefit

Product Availability:

Lotion: 0.05% (0.5 mg/g)

References:

1. Ultravate lotion [Prescribing Information]. Jacksonville, FL: Ranbaxy Laboratories; November 2015.
2. Ultravate cream/ointment [Prescribing Information]. Jacksonville, FL: Ranbaxy Laboratories; March 2012.