CurrentCignaPolicy N/A

Hydrocortisone Acetate Suppository Step Therapy Policy

Cigna step therapy policy governing coverage of hydrocortisone acetate suppository products (generic and branded/generic products such as Anucort-HC, Hemmorex-HC, Anusol-HC, Proctocort) requiring trial of Step 1 products prior to Step 2 products; approvals provided for 1 year.

Policy Summary

PayerCigna

PolicyHydrocortisone Acetate Suppository Step Therapy Policy

Policy CodePolicy N/A

Change TypeClarified (annual review, no criteria changes)

Effective DateN/A

Next Review DateN/A

Key ActionDocument that the patient has tried one Step 1 Product to support approval of a Step 2 Product; approvals are provided for 1 year.

SourceLink

POLICY UPDATE CHANGES

Annual revisions noted with 'No criteria changes' for review dates 01/17/2024, 01/22/2025, and 01/14/2026.

2Step levels (Step 1, Step 2)

1 yrApproval duration

No criteria changesRecent annual reviews

Coverage Summary

Cigna step therapy policy governing coverage of hydrocortisone acetate suppository products requires a trial of a Step 1 product prior to approval of Step 2 products. Coverage stance: covered_with_criteria. Applicable product types include generic and branded/generic hydrocortisone acetate suppositories. Approvals are provided for 1 year.

Step Therapy Coverage Criteria

Hydrocortisone Acetate Suppository Step Therapy Policy product(s) are covered as medically necessary when the following step therapy criteria are met. Any other exception is considered not medically necessary. All approvals are provided for 1 year in duration.

Step 1 Products (preferred first-line): Step 1: generic hydrocortisone acetate suppository (25 mg or 30 mg), Anucort-HC (25 mg), Hemmorex-HC (25 mg or 30 mg)
Step 2 Products (require prior trial of Step 1): Step 2: Anusol-HC (25 mg), Proctocort (30 mg)

Operational Note: Approvals are provided for 1 year in duration.

Applicable Codes

Step 1 Products (preferred first-line)mixedCovered

generic hydrocortisone acetate suppository 25 mg	generic hydrocortisone acetate suppository (25 mg)
generic hydrocortisone acetate suppository 30 mg	generic hydrocortisone acetate suppository (30 mg)
Anucort-HC 25 mg	Anucort-HC (hydrocortisone acetate 25 mg suppository) - branded generic (Cosette)
Hemmorex-HC 25 mg	Hemmorex-HC (hydrocortisone acetate 25 mg suppository) - branded generic (Laser)
Hemmorex-HC 30 mg	Hemmorex-HC (hydrocortisone acetate 30 mg suppository) - branded generic (Laser)

Step 2 Products (require prior trial of Step 1)mixedCovered

Anusol-HC 25 mg	Anusol-HC (hydrocortisone acetate 25 mg suppository) - brand (Salix)/generic
Proctocort 30 mg	Proctocort (hydrocortisone acetate 30 mg suppository) - brand (Salix)/generic

Step 2 products require a prior trial of a Step 1 product before approval. All approvals are provided for 1 year. Examples of products include branded/generic items such as Anusol-HC and Proctocort, and Step 1 examples include Anucort-HC and Hemmorex-HC.

Provider Actions

Step Therapy

Step therapy enforcement at point of service

If the Step Therapy rule is not met for a Step 2 Product at the point of service, coverage will be determined by the Step Therapy criteria; a patient must have tried one Step 1 Product before a Step 2 Product is approved. All approvals are provided for 1 year.

Anusol-HC 25 mg
Proctocort 30 mg

Documentation Required

Document trial of Step 1 product

Provider must document that the patient has tried one Step 1 Product (specified generic or branded generic hydrocortisone acetate suppository 25 mg or 30 mg) to support approval of a Step 2 Product.

Background

Hydrocortisone acetate suppositories are indicated for management of inflamed hemorrhoids, postirradiation proctitis, as an adjunct in the treatment of chronic ulcerative colitis, cryptitis, other inflammatory anorectal conditions, and pruritus ani. Multiple branded and generic products are available.

Quick Facts

Step levels2

Approval duration1 year

Recent annual reviewsNo criteria changes

Revision History

2024-01-17annual_review

Annual review — no clinical criteria changes.

2025-01-22annual_review

Annual review — no clinical criteria changes.

2026-01-14annual_reviewLatest

Annual review — no clinical criteria changes.

Policy Summary

PayerCigna

PolicyHydrocortisone Acetate Suppository Step Therapy Policy

Policy CodePolicy N/A

Change TypeClarified (annual review, no criteria changes)

Effective DateN/A

Next Review DateN/A

Key ActionDocument that the patient has tried one Step 1 Product to support approval of a Step 2 Product; approvals are provided for 1 year.

SourceLink

On This Page

OpenPayer

Hydrocortisone Acetate Suppository Step Therapy Policy

Coverage Summary

Applicable Codes

Provider Actions

Clinical Evidence & References

Background

Revision History