Xerese (acyclovir 5% and hydrocortisone 1%) topical cream — Highmark

Preferred products

• generic acyclovir 5% ointment
• hydrocortisone 1% cream

Initial criteria

• age ≥ 6 years
• Diagnosis of recurrent herpes labialis (cold sores) (ICD-10: B00.1)
• Therapeutic failure or intolerance to generic oral acyclovir
• Therapeutic failure or intolerance to one (1) of the following generic oral antivirals, or both are contraindicated: valacyclovir OR famciclovir
• Therapeutic failure or intolerance to plan-preferred generic acyclovir 5% ointment and hydrocortisone 1% cream, available separately and used together

Reauthorization criteria

• Prescriber attests member has experienced positive clinical response to therapy
• Member has experienced therapeutic failure or intolerance to plan-preferred generic acyclovir 5% ointment and hydrocortisone 1% cream, available separately and used together

Approval duration

12 months