doxepin hydrochloride cream 5% — Blue Cross Blue Shield of Montana
pruritus associated with lichen simplex chronicus
Initial criteria
- Requested quantity does NOT exceed program quantity limit OR
- Requested quantity exceeds program limit AND ONE of the following: (A) BOTH: (1) agent lacks a maximum FDA labeled dose for the requested indication AND (2) support for higher dose exists OR (B) requested dose does NOT exceed maximum FDA labeled dose for indication OR (C) BOTH: (1) requested dose exceeds maximum FDA labeled dose AND (2) support exists for higher dose therapy for that indication
Reauthorization criteria
- Criteria remain satisfied; continued medical necessity
Approval duration
BCBSIL: 12 months; all other plans: 1 month for pruritus associated with atopic dermatitis or lichen simplex chronicus, else 12 months