acyclovir 5% ointment — Medica
Limited non-life-threatening mucocutaneous herpes simplex virus infections
Preferred products
- generic acyclovir 5% ointment
Initial criteria
- Patient is immunocompromised
- Generic acyclovir 5% ointment is requested OR
- Patient has tried generic acyclovir 5% ointment AND patient cannot use the generic product due to a formulation difference in the inactive ingredient(s) 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