CurrentCignaPolicy N/A

Topical Doxepin Step Therapy Policy

Defines step therapy requirements for coverage of topical doxepin 5% creams (Prudoxin, Zonalon, generics) under Cigna-administered health benefit plans; affects providers prescribing topical doxepin for adult pruritus conditions.

Policy Summary

PayerCigna

PolicyTopical Doxepin Step Therapy Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization for Step 2 topical doxepin requires documentation that the patient has tried two Step 1 prescription topical corticosteroid products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Step 1 products required

8Max short-term use (days)

2 monthsApproval duration

5%Doxepin concentration

Coverage Criteria for Topical Doxepin Cream

Initial Step Therapy Criteria

Covered when ALL of the following are met

Initial Step Therapy Criteria: Patient has tried two Step 1 products (generic prescription topical corticosteroids per Table 1).2 products

If met, approve a Step 2 product for 2 months.

Any use of a Step 2 topical doxepin product (for example, Doxepin cream, Prudoxin cream, or Zonalon cream) without first meeting the Step 1 requirement is considered not medically necessary unless an exception is documented and meets the program’s Step Therapy criteria. The program requires trial of Step 1 therapies before Step 2; approvals for Step 2 products are only provided when the Step Therapy rule is satisfied and are issued for 2 months.

Use of a Step 2 product when the patient has not tried two Step 1 prescription topical corticosteroid products (see Table 1 for Step 1 agents) is considered not medically necessary. If the patient has tried two Step 1 products, a Step 2 product may be approved for 2 months.

Provider Actions, Prior Authorization, and Billing

Policy Summary

PayerCigna

PolicyTopical Doxepin Step Therapy Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization for Step 2 topical doxepin requires documentation that the patient has tried two Step 1 prescription topical corticosteroid products.

SourceLink

On This Page

Documentation Required

Billing and documentation expectations

Providers must submit claims using the most appropriate diagnosis and procedure/drug codes in effect on the date of service. Coverage determinations depend on the applicable benefit plan document and submitted documentation. Claims submitted without covered code(s) or without required supporting information may be denied as not covered or not medically necessary.

Submit supporting clinical documentation that demonstrates prior trials of Step 1 products when requesting coverage for a Step 2 product
Include pertinent diagnosis codes that justify the medical necessity per the applicable benefit plan
Ensure drug-specific billing codes/NDCs and quantities match the approved product and duration

Step Therapy

Step 1 then Step 2 requirement

Step therapy requires that patients try two Step 1 prescription topical corticosteroid products before a Step 2 topical doxepin product will be approved. If documentation shows the patient has tried two Step 1 products, approve a Step 2 product for a 2-month duration (approvals provided in months; 1 month = 30 days).

Step 1: generic prescription topical corticosteroids (see Table 1)
Step 2: Doxepin cream, Prudoxin cream, Zonalon cream
Approvals are provided for 2 months in duration (1 month = 30 days)

OpenPayer

Topical Doxepin Step Therapy Policy

Coverage Criteria for Topical Doxepin Cream

Provider Actions, Prior Authorization, and Billing

Definitions

Background