CurrentCentenePolicy CP PMN.167

Neomycin/Fluocinolone (Neo-Synalar) cream coverage

Defines medical necessity and prior authorization criteria for Neo-Synalar topical cream for corticosteroid-responsive dermatoses with secondary infection for Centene lines of business.

Policy Summary

PayerCentene

PolicyNeomycin/Fluocinolone (Neo-Synalar) cream coverage

Policy CodePolicy CP PMN.167

Change TypeNo material change

Effective Date12.01.18

Next Review Date

Key ActionObtain prior authorization and submit documentation showing failure of a formulary topical antibacterial to receive an initial 14‑day approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysInitial approval duration

2Max tubes/course

120 gMax grams/course

0.5%/0.025%Concentration

2–4x/dayDosing

Coverage Criteria

Policy Summary

PayerCentene

PolicyNeomycin/Fluocinolone (Neo-Synalar) cream coverage

Policy CodePolicy CP PMN.167

Change TypeNo material change

Effective Date12.01.18

Next Review Date

Key ActionObtain prior authorization and submit documentation showing failure of a formulary topical antibacterial to receive an initial 14‑day approval.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Approval Criteria

Neo-Synalar is medically necessary when ALL of the following are met:

Diagnosis of a corticosteroid-responsive dermatosis (examples: eczema, psoriasis, poison ivy/oak/sumac, insect bites, atopic dermatitis, seborrheic dermatitis)

Therapeutic failure or contraindication: Failure of a formulary topical antibacterial product at up to maximally indicated doses unless clinically significant adverse effects occur or all formulary topical antibacterials are contraindicated (see Appendix B)

Provider must submit documentation (office chart notes, lab results or other clinical information)

Dose limits: Dose does not exceed two tubes per treatment course and 120 g per treatment coursetwo tubes; 120 g

Approval duration: 14 days

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial approvals are granted for 14 days and are subject to dose limits: a maximum of two tubes per treatment course and 120 g per treatment course. Requests must include documentation supporting that the member meets all approval criteria (office chart notes, lab results, or other clinical information).

Approval duration: 14 days
Dose limits: Two tubes per treatment course; 120 g per treatment course
Required documentation: office chart notes, lab results, or other clinical information

Step Therapy

Therapeutic Alternatives Requirement

Must have failure of a formulary topical antibacterial at maximally indicated doses unless clinically significant adverse effects or contraindications are documented. See Appendix B (Therapeutic Alternatives) for preferred alternative topical antibacterial agents and dosing regimens.

Therapeutic alternatives listed in Appendix B (e.g., neomycin/polymyxin B/bacitracin, bacitracin/polymyxin B)
Failure trial should be at maximally indicated doses unless adverse effects or contraindications are present

Documentation Required

Required Documentation

Provider must submit supporting documentation with the prior authorization request — for example, office chart notes, laboratory results, or other clinical information demonstrating the member meets all approval criteria (diagnosis of a corticosteroid‑responsive dermatosis and prior therapeutic trial when required).

Examples of acceptable documentation: office notes, lab results, clinical progress notes

Denial Risk

Non‑FDA Indications / Off‑Label Requests

Requests for indications not FDA‑approved and not addressed in this policy will be denied unless sufficient off‑label documentation of efficacy and safety is provided consistent with the plan's off‑label use policies (CP.CPA.09, HIM.PA.154, CPPMN.53) or applicable evidence of coverage documents.

Non‑FDA indications require adequate off‑label evidence per applicable off‑label policies or evidence of coverage

Definitions

Corticosteroid‑responsive dermatoses — examples

DefinitionDermatoses that respond to topical corticosteroids and may have secondary infection (examples: eczema, psoriasis, poison ivy/oak/sumac, insect bites, atopic dermatitis, seborrheic dermatitis)

Clinical contextNeo‑Synalar (neomycin/fluocinolone cream) is indicated for corticosteroid‑responsive dermatoses with secondary infection

Efficacy noteThe combination has not been shown to provide greater benefit than the steroid component alone after 7 days of treatment

Product descriptionCombination topical antibacterial and corticosteroid cream (neomycin/fluocinolone)

OpenPayer

Neomycin/Fluocinolone (Neo-Synalar) cream coverage

Coverage Criteria

Provider Actions and Prior Authorization

Background

Definitions