CurrentCignaPolicy N/A

Topical Corticosteroids - Clobetasol Drug Quantity Management Policy - Per Days

Cigna Drug Quantity Management policy governing quantity limits, one-time override criteria, and coverage rules for topical clobetasol products (various formulations and brands/generics) across retail and home delivery channels. Applies to health benefit plans administered by Cigna companies and defines allowed quantities per 28-day and 84-day periods and conditions for approving additional quantities.

Policy Summary

PayerCigna

PolicyTopical Corticosteroids - Clobetasol Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeClarified

Effective Date

Next Review Date

Key ActionIf Drug Quantity Management limits are not met at point of service, determine coverage using the specified criteria and calculate approval quantities per retail (past 28 days + override) or home delivery (past 84 days + override); one-time approvals are 30 days.

SourceLink

POLICY UPDATE CHANGES

Policy updated to reflect existing quantity limits for home delivery and to specify override calculation notes for several products.

12Listed products/formulations

120 gRetail common per 28 days

360 gHome delivery common per 84 days

30 days

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Coverage Summary

Coverage stance: covered_with_criteria for topical clobetasol products per the Cigna Drug Quantity Management policy. Scope: this policy governs quantity limits, one-time override criteria, and coverage rules for multiple clobetasol formulations and brands/generics across retail and home delivery channels and applies to health benefit plans administered by Cigna companies. One-time overrides are allowed and are provided for 30 days in duration. Effective/last review date: 04/03/2025.

Product-specific One-time Override Criteria

Not Medically Necessary / Exclusions

Provider Actions / Prior Authorization

Prior Authorization

Drug Quantity Management rule applies at point of service

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the specified criteria; approvals are provided for the durations noted and one-time approvals are 30 days.

Documentation Required

Calculate approval quantity for overrides

For the specified products below, calculate the approval quantity for a one-time override as: at retail = amount received in the past 28 days plus the override amount; at home delivery = amount received in the past 84 days plus the override amount.

Clobetasol emollient cream (generic): retail = grams received in past 28 days + 120 grams; home delivery = grams received in past 84 days + 120 grams.
Clobetasol lotion (Clobex, generic): retail = mLs received in past 28 days + 118 mL; home delivery = mLs received in past 84 days + 118 mL.
Clobetasol spray (Clobex, generic): retail = mLs received in past 28 days + 125 mL; home delivery = mLs received in past 84 days + 125 mL.
Impeklo lotion: retail = grams received in past 28 days + 138 grams; home delivery = grams received in past 84 days + 138 grams.

Denial Risk

Overrides not allowed for compounded formulations

Requests for additional quantities for compounded formulations should be denied as not medically necessary.

Billing Rule

Use most appropriate codes and covered diagnosis codes

Claims submitted without covered diagnosis or procedure codes under the applicable coverage policy will be denied as not covered; providers must use the most appropriate codes as of the submission effective date.

Applicable Products / Codes

Products / formulation list (no procedure codes provided)mixed

	clobetasol cream 0.05% (generic only)
	clobetasol emollient cream 0.05% (generic only)
	clobetasol gel 0.05% (generic only)
	clobetasol solution 0.05% (generic only)
	Clobex (clobetasol lotion/shampoo/spray 0.05%, generic)
	Clodan (clobetasol shampoo 0.05%, generic)
	Clodan Kit (clobetasol shampoo 0.05% + Rehyla Hair & Body Cleanser)
	Impeklo (clobetasol lotion 0.05%, metered dose pump)
	Impoyz (clobetasol cream 0.025%, authorized generic)
	Olux (clobetasol foam 0.05%, generic)

1–10 of 12

1/2

No procedure (CPT/HCPCS/ICD-10) codes were provided in the policy. Claims submitted without covered diagnosis/procedure codes will be denied; providers must include appropriate covered diagnosis or procedure codes and should use the most appropriate codes as of the submission effective date.

Background

Background: Clobetasol propionate is a super-high potency topical corticosteroid indicated for inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, including plaque psoriasis and scalp psoriasis, with age- and formulation-specific labeling. Most topical clobetasol products are applied BID for up to 2 consecutive weeks; for some psoriasis indications, treatment may be extended up to 4 weeks for localized lesions. The Drug Quantity Management program exists to prevent stockpiling, misuse, and overuse by limiting allowed quantities per period and requiring overrides (one-time approvals) for additional supplies.

Definitions:

• One-time override: A single approval for an additional quantity provided for 30 days in duration.

• Retail approval quantity calculation: The number of grams or mLs received in the past 28 days plus the specified additional amount for the product (e.g., +120 g for clobetasol emollient cream; +118 mL for clobetasol lotion; +125 mL for clobetasol spray; +138 g for Impeklo).

• Home delivery approval quantity calculation: The number of grams or mLs received in the past 84 days plus the specified additional amount for the product (e.g., +120 g, +118 mL, +125 mL, +138 g as applicable).

Clinical Evidence / Review

Evidence summary: Review date in header: 2025-04-03. No trial metrics or additional quantitative trial evidence are provided in the policy.

Revision History

clarified

Policy updated to reflect existing quantity limits when product is obtained via home delivery and to specify override criteria wording for clobetasol emollient cream, clobetasol lotion, clobetasol spray, Impeklo lotion, and related products; Impoyz 0.025% (authorized generic) added and Temovate brand removed as obsolete. One-time approvals are provided for 30 days; override calculations note retail = amount received in past 28 days + specified amount and home delivery = amount received in past 84 days + specified amount.

2025-04-03Last reviewLatest

Review date recorded as 04/03/2025 for the Drug Quantity Management policy.