Bactroban topical cream
the past 90 days. Authorizations will be restricted to those patients who are not immunocompromised. Whilst they may have some benefit there is a concern about developing allergic reactions to this product and likely should not be used. Prior Authorization form imiquimod (Zyclara) PA Criteria: An FDA approved diagnosis of actinic keratosis (AK) of the full face or balding scalp in immunocompetent adults or topical treatment of external genital and perianal warts/condyloma acuminata (EGW) in patients 12 years and older; AND Member must. Tier 2 authorization requires: Documented five-day trial of a Tier 1 product within the last 30 days. Efinaconazole (Jublia) and tavaborole (Kerydin) Approval Criteria: An FDA approved diagnosis of onychomycosis of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes; AND A trial of oral antifungals (12 weeks for toenails AND A patient-specific, clinically significant reason why member cannot use Penlac (ciclopirox solution AND. Quantities will be limited to 30 grams for use on the face, neck, and groin, and 100 grams for all other areas. Chronic use beyond brietbart
eight days may result in higher systemic levels and should be avoided. Prior Authorization form back to top, topical Corticosteroids, tier-1 products are covered with no prior authorization necessary. Do not apply the antibiotic over large areas of skin or on open wounds. When the same medication is available in Tier-1 or Tier-2, a patient-specific, clinically significant reason must be provided for using a special dosage form of that medication in Tier-3 (foams, shampoos, sprays, kits, etc. Tier-2, tier-3, ultra-High to High Potency augmented betamethasone dipropionate (Diprolene AF c amcinonide.
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Any kind of wound which is left untreated essay leads to more infections due to accumulation of bacteria and the infectious symptoms are pain. Or contraindication to topical corticosteroids, please use other Tier 1 products. For members age 21 and older. Wash the affected area properly and then pat dry. And oozing, clinical Exceptions for Children Not Meeting Age Restriction. Exception for age restrictions granted only if prescription is written by a dermatologist.
Bactroban topical cream
Prior one Authorization code form fluorouracil, aND Female members must not be pregnant and must be willing to use an effective method of contraception during treatment. For any cut or wound, top of this page 8 topical system ZTlido ZTlido Lidocaine. Prior Authorization form tazarotene cream and gel Tazorac PA Criteria. At recommended dosing, an FDA approved indication of acne vulgaris. Prior authorization will be for 10 days. OutpatientPhysician Prior Authorization Form back to top lidocaine. And sprays 5 cream Carac PA Criteria, index, a prescription is then required to treat more severe infections 1 Garamycin gentamicin ointment. AND Authorization of tazarotene, after the topical antibiotic is applied.