Klisyri 1% ointment — Medical Mutual

Preferred products

• fluorouracil 2% solution
• fluorouracil 5% solution
• fluorouracil 5% cream
• imiquimod 5% cream

Initial criteria

• If the patient has tried one preferred product, then authorization for a non-preferred product may be given.
• Step Therapy Exception Criteria: Approve for 1 year if the patient meets ONE of the following (A, B, or C):
• A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents; OR
• B. The patient has a contraindication to all preferred agents; OR
• C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
• 1. The patient has at least 130 days of prescription claims history on file and claims history supports that the patient has received the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested nonpreferred product; OR
• 2. When 130 days of the patient’s prescription claims history file is unavailable for verification, the prescriber must verify that the patient has been receiving the requested non-preferred agent for 90 days AND that the patient has been receiving the requested non-preferred agent via paid claims AND there is no generic equivalent available for the requested nonpreferred product.

Reauthorization criteria

• All approvals for continuation of therapy are provided for 1 year unless noted otherwise.

Approval duration

1 year