Zovirax (acyclovir) topical cream — Highmark

Preferred products

• generic acyclovir 5% ointment

Initial criteria

• age ≥ 12 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

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

Approval duration

12 months