Zonalon — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) The patient has a diagnosis of moderate pruritus associated with atopic dermatitis AND ONE of the following: (1) The patient has tried and had an inadequate response to BOTH a topical corticosteroid used for a minimum of 4 weeks AND a topical calcineurin inhibitor used for a minimum of 6 weeks OR (2) The patient has an intolerance or hypersensitivity to a topical corticosteroid AND a topical calcineurin inhibitor OR (3) The patient has an FDA labeled contraindication to ALL topical corticosteroids AND topical calcineurin inhibitors OR (B) The patient has a diagnosis of moderate pruritus associated with lichen simplex chronicus AND ONE of the following: (1) The patient has tried and had an inadequate response to ONE topical corticosteroid OR (2) The patient has an intolerance or hypersensitivity to ONE topical corticosteroid OR (3) The patient has an FDA labeled contraindication to ALL topical corticosteroids OR (C) The patient has another FDA labeled indication for the requested agent and route of administration OR (D) The patient has another indication that is supported in compendia for the requested agent and route of administration
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• If request is for one of the brand agents with an available generic, then ONE of the following: (A) The patient is currently treated with and stable on the requested agent [chart notes required] OR (B) The patient has tried and had inadequate response to the generic [chart notes required] OR (C) The generic was discontinued due to lack of efficacy or adverse event [chart notes required] OR (D) The patient has intolerance or hypersensitivity to the generic not expected to occur with the brand [chart notes required] OR (E) The patient has FDA labeled contraindication to the generic not expected with the brand [chart notes required] OR (F) The generic is expected to be ineffective or cause a significant barrier to adherence or worsen a comorbid condition or cause harm [chart notes required] OR (G) The generic is not in the best interest of the patient based on medical necessity [chart notes required] OR (H) The patient has tried another drug in the same class/mechanism that was discontinued due to lack of efficacy or adverse event [chart notes required] OR (I) There is support for use of requested brand agent over generic
• The patient will NOT be using the requested agent in combination with another topical doxepin agent for the requested indication
• The patient has NOT already received 8 days of therapy with a topical doxepin agent for the current course of therapy
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL, BCBSMT); BCBSNM: 3 months for pruritus associated with atopic dermatitis or lichen simplex chronicus or 12 months for other requests; All other plans: 1 month for pruritus associated with atopic dermatitis or lichen simplex chronicus or 12 months for other requests