Zovirax (acyclovir 5% ointment – Bausch Health, generic) — Cigna
Limited Non-Life-Threatening Mucocutaneous Herpes Simplex Virus Infections
Preferred products
- acyclovir 5% ointment
Initial criteria
- Patient is immunocompromised
- Generic acyclovir 5% ointment is requested OR
- (a) Patient has tried generic acyclovir 5% ointment AND (b) Patient cannot use the generic product due to a formulation difference in the inactive ingredient(s) [e.g., difference in buffers, emollients, emulsifiers, preservatives, surfactants] between the brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction
Approval duration
1 year