CurrentCentenePolicy HIM.PA.20

Halcinonide (Halog) (PDF)

Defines medical necessity, prior authorization and utilization limits for Halcinonide (Halog) cream and ointment for dermatologic inflammation and pruritus within Centene-affiliated health plans (HIM line of business). Includes initial and continued therapy criteria, dose limits, exclusions, therapeutic alternatives, contraindications, product availability and administrative notes.

Policy Summary

PayerCentene

PolicyHalcinonide (Halog) (PDF)

Policy CodePolicy HIM.PA.20

Change TypeStep therapy updategeneric redirectionproduct availability

Effective DateAug 28, 2018

Next Review Date

Key ActionProvider must obtain prior authorization where required and submit documentation supporting that the member met all approval criteria.

SourceLink

POLICY UPDATE CHANGES

Added step therapy bypass for IL HIM per IL HB 5395 and revised redirection to generic halcinonide cream for brand Halog cream requests for IL HIM.

Added redirection to generic halcinonide cream for brand Halog requests and noted prior authorization may be required for generic halcinonide cream.

Removed 30 g ointment tube formulation as it is no longer commercially available.

References reviewed and updated in multiple annual reviews (2021-2025); no significant clinical changes for most reviews.

1Covered primary indication (dermatologic inflammation/pruritus)

2Required prior failures (high potency corticosteroids)

60 g

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Monthly quantity limit (grams)

12 monthsApproval duration

Coverage Summary

Coverage stance: covered_with_criteria for the FDA-approved indication of relief of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. Policy scope: Defines medical necessity, prior authorization and utilization limits for Halcinonide (Halog) cream and ointment for dermatologic inflammation and pruritus within Centene-affiliated health plans (HIM line of business). Product availability: cream 0.1%: 30 g, 60 g; ointment 0.1%: 60 g. Contraindication: hypersensitivity to any component of the preparation. Approval duration: 12 months. Status: CURRENT. Policy number: HIM.PA.20. Line of business: HIM.

Thresholds and Quick Facts

Monthly quantity limit<= 60 gm per month

Tube limit<= 1 tube per month

Maximum applications per day<= 3 applications/day (maximum dose)

Required prior failuresFailure of two formulary high‑potency topical corticosteroids in the previous 6 months, unless contraindicated or significant adverse effects

Approval duration12 months

Initial Therapy Criteria

I. Initial Approval Criteria - Dermatologic Inflammation and Pruritus

Covered when ALL of the following are met:

ALL of the following

Diagnosis of dermatologic inflammation or pruritus.
Failure of two formulary high-potency topical corticosteroids in the previous 6 months, unless contraindicated or clinically significant adverse effects are experienced (see Appendix B for examples).
For Illinois HIM requests, the step therapy requirements above do not apply as of 2026-01-01 per IL HB 5395.
Generic-use redirection
- If request is for brand Halog cream or ointment, member must use generic halcinonide cream.

Continuation Therapy Criteria

Unapproved Indications / Exclusions

III. Diagnoses/Indications Not Authorized

Coverage not authorized when:

III. Diagnoses/Indications Not Authorized: Non-FDA approved indications which are not addressed in this policy are not authorized unless sufficient documentation of efficacy and safety is provided per off-label use policies or evidence of coverage documents

Refer to off-label use policy HIM.PA.154 or evidence of coverage documents

Provider Actions & Administrative Requirements

Prior Authorization

Prior authorization required for Halog/generic

Provider must obtain prior authorization where required and submit documentation (office chart notes, lab results or other clinical information) supporting that the member met all approval criteria. Note: prior authorization may also be required for generic halcinonide cream depending on formulary.

Documentation: office chart notes, lab results, other clinical information

Step Therapy

Step therapy requirement

Prior failure of two formulary high‑potency topical corticosteroids within the previous 6 months is required unless contraindicated or clinically significant adverse effects are experienced. For Illinois HIM requests, step therapy requirements do not apply as of 2026-01-01 per IL HB 5395; brand Halog cream requests are redirected to generic halcinonide cream.

Applicable Codes & References

Relevant policy/reference numbersmixed

HIM.PA.20	Clinical Policy Reference Number for Halcinonide (Halog)
HIM.PA.154	Off-label use policy referenced for HIM
HIM.PA.33	No coverage criteria policy for formulary drugs (HIM)
HIM.PA.103	Nonformulary policy for HIM
CC.PHARM.03A	State specific continuity of care addendum A
CC.PHARM.03B	State specific continuity of care addendum B

Clinical Evidence & Indication

Evidence: FDA approved indication — Relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. Therapeutic alternatives: policy provides other high-potency topical corticosteroids as alternatives (see Appendix B).

Background & Definitions

Background: Halcinonide (Halog) is a high-potency topical corticosteroid with anti-inflammatory and antipruritic actions. Dosing/administration guidance: apply to the affected area BID to TID with a maximum of 3 applications/day. Product availability: cream 0.1%: 30 g, 60 g; ointment 0.1%: 60 g. Contraindication: history of hypersensitivity to any component of the preparation. Therapeutic alternatives: other high-potency topical corticosteroids are listed in Appendix B as preferred alternatives.

Revision History

4Q 2025 (effective for IL HIM 2026-01-01)revisedLatest

Referenced in 4Q 2025 annual review; added step therapy bypass for Illinois HIM per IL HB 5395 and revised redirection to generic halcinonide cream for brand Halog cream requests (effective for IL HIM as of 2026-01-01).

4Q 2023clarified

Applied clarification in 4Q 2023 annual review: added redirection to generic halcinonide cream for brand Halog requests in continued therapy section and added note that prior authorization may be required for generic halcinonide cream; references reviewed and updated.

Policy Summary

PayerCentene

PolicyHalcinonide (Halog) (PDF)

Policy CodePolicy HIM.PA.20

Change TypeStep therapy updategeneric redirectionproduct availability

Effective DateAug 28, 2018

Next Review Date

Key ActionProvider must obtain prior authorization where required and submit documentation supporting that the member met all approval criteria.

SourceLink

On This Page

For Illinois HIM requests only: If request is for brand Halog cream, member must use generic halcinonide cream.

Dose/quantity limits

Dose does not exceed 60 gm per month.<= 60 gm/month
One tube per month maximum.<= 1 tube/month

Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.

Provider documentation required.

Prior authorization may be required for generic halcinonide cream.

Operational: prior authorization may apply to generic cream depending on formulary and line of business.

Approval duration: 12 months.<= 12 months

I. Initial Approval Criteria - Other diagnoses/indications

If NONE of the specific initial criteria above apply, the request may still be considered under the policies below (meet 1 OR 2):

ANY of the following

If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to the appropriate formulary/no-coverage or nonformulary policy for the relevant line of business: HIM.PA.33 (formulary/no-coverage) or HIM.PA.103 (nonformulary).
If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: HIM.PA.154.

Documentation Required

Continuity of care documentation

For continued therapy, providers must document a positive response to treatment and either prior approval/met initial criteria or that the member is enrolled in a state/product with continuity of care regulations (refer to CC.PHARM.03A and CC.PHARM.03B).

Billing Rule

Dose/quantity limits enforcement

Claims may be limited or denied if the monthly quantity exceeds 60 g, if more than one tube is supplied per month, or if dosing exceeds the maximum of 3 applications per day.

Monthly quantity limit: 60 gm per month
Tube limit: One tube per month
Maximum dosing: 3 applications/day
Enforcement: claims may be limited or denied if thresholds exceeded

Documented in 4Q 2022 annual review: added redirection to generic halcinonide cream for brand Halog requests and removed 30 g ointment tube formulation as it is no longer commercially available; references reviewed and updated.

4Q 2021revised

4Q 2021 annual review: no significant changes; updated reference for HIM off-label use to HIM.PA.154 and references reviewed and updated.

4Q 2024revised

4Q 2024 annual review: no significant clinical changes; references reviewed and updated.