CurrentCignaPolicy N/A

Topical Corticosteroids - Diflorasone Drug Quantity Management Policy

Defines drug quantity limits and medical necessity criteria for diflorasone 0.05% cream and ointment (generic only) for Cigna-administered health benefit plans, including retail and home delivery supply rules and exceptions.

Policy Summary

PayerCigna

PolicyTopical Corticosteroids - Diflorasone Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateNov 5, 2025

Key ActionRequest prior authorization for exceptions to quantity limits; approvals are granted for one year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 gDefault retail maximum per 30 days

360 gDefault home delivery per 90 days

180 gMax retail with criteria

540 gMax home delivery with criteria

0.05%Product concentration

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Coverage Criteria & Exceptions

Quantity limits and exceptions

Covered with quantity limits; exceptions approved when ALL of the following criteria apply as specified below

Default quantity limits: Diflorasone 0.05% cream: retail maximum 120 grams per 30 days; home delivery maximum 360 grams per 90 days. Diflorasone 0.05% ointment: retail maximum 120 grams per 30 days; home delivery maximum 360 grams per 90 days.

Approvals are provided for 1 year when criteria are met.

No overrides are recommended for use in any compounded formulations.

Any exception to the listed quantity limits not meeting the specified criteria is considered not medically necessary.

Billing / Coding

Billing/coding requirementmixed

affected codes

Providers must use most appropriate codes; claims without covered codes will be denied

Body surface area treated — > 8% BSA

Threshold> 8% body surface area (BSA)

Use caseRequired for approval of quantities above the default limits (exception criteria)

Measurement basisDetermined using fingertip unit (FTU) estimates (1 g ≈ 4% BSA; 0.5 g ≈ 2% BSA)

Provider Actions & Documentation

Prior Authorization

Prior authorization for quantity exceptions — 1-year approvals

Approvals for exceptions to Drug Quantity Limits are provided for one year when criteria are met. If the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the criteria in this policy.

Exceptions to quantity limits are considered medically necessary only when the listed criteria are met.
If the rule is not met at point of service, prior authorization or clinical review may be required to determine coverage.

Note

Provider action required

When submitting requests for quantity exceptions or appeals, provide clear documentation of the clinical rationale and specific provider actions taken (diagnosis, body surface area affected, dosing frequency, and quantity requested).

Document % BSA treated and frequency of application.
Include the exact quantity requested and desired days' supply (retail per 30 days or home delivery per 90 days).

Clinical Background

Diflorasone is a high-potency topical corticosteroid indicated for inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses such as psoriasis and atopic dermatitis. Cream and ointment formulations have recommended application frequencies and are available in multiple tube sizes; dosing and quantity expectations are informed by the fingertip unit (FTU) method and body surface area treated. Quantity management rules limit retail supply to 120 g per 30 days (standard) with home delivery limits applied per 90 days; exceptions allowing up to 180 g per 30 days (retail) or 540 g per 90 days (home delivery) require documented criteria to be met.

Key Definitions

FTU (fingertip unit)

DefinitionFingertip unit (FTU): amount squeezed from a standard tube along an adult fingertip (≈0.5 g)

Coverage per FTUOne FTU covers ~2% of an adult's body surface area (BSA)

1 g equivalence1 g of topical corticosteroid covers approximately 4% of adult BSA

Clinical useQuantity limits use FTU method to estimate supply needed for treatment (e.g., ~8% BSA when applied twice daily for 30 days)

Initial Therapy — Dosing & Availability

Dosing and product availability

Standard application and product availability inform quantity limits

Standard dosing assumptions: Diflorasone 0.05% cream: applied up to twice daily; available in 30 g and 60 g tubes. Diflorasone 0.05% ointment: applied once to three times daily; available in 15 g, 30 g, 45 g, and 60 g tubes.

Quantity rationale (FTU method): Using the fingertip unit (FTU) method, 1 FTU ≈ 0.5 g ≈ 2% adult BSA; 1 g covers ≈4% BSA. The retail and home delivery quantity limits approximate enough product to cover ~8% BSA when applied twice daily for 30 days (retail) or 90 days (home delivery).

Quantity limits informed by typical tube sizes and expected applications per day.

Step Therapy / Exception Documentation

Step	Requirement	Approval limits	Duration / Notes
2
Documentation that the patient is using diflorasone 0.05% (cream or ointment) for an FDA‑approved indication and needs to administer more frequently than twice daily
Approve quantity requested up to 180 grams per 30 days (retail) or 540 grams per 90 days (home delivery)
Approvals provided for 1 year; if Drug Quantity Management rule not met at point of service, coverage determined by criteria

Quantity Limits by Product & Supply

diflorasone 0.05% cream (generic only) — 120 grams

Product and concentrationdiflorasone 0.05% cream (generic only)

Default retail limit120 grams per 30 days

Package sizes notedAvailable in 30 g and 60 g tubes (per policy listing)

diflorasone 0.05% cream (generic only) — 360 grams

Product and concentrationdiflorasone 0.05% cream (generic only)

Default home delivery limit360 grams per 90 days

Exception maximum

Retail vs Home Delivery

Billing Rule

Retail vs home delivery quantity rules

Retail quantity limits are applied per 30 days; home delivery limits are applied per 90 days — confirm the dispensing channel when requesting or billing larger supplies.

Retail maximums (default): 120 g per 30 days
Home delivery maximums (default): 360 g per 90 days
Exception maximums: up to 180 g per 30 days (retail) or 540 g per 90 days (home delivery) when criteria met

Policy Summary

PayerCigna

PolicyTopical Corticosteroids - Diflorasone Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateNov 5, 2025

Key ActionRequest prior authorization for exceptions to quantity limits; approvals are granted for one year when criteria are met.

SourceLink

On This Page

Documentation Required

Required documentation and coding

Coverage determinations require consideration of the applicable benefit plan document, any controlling laws/regulations, relevant collateral materials (including this coverage policy), and the specific facts of the individual case. Medical directors may exercise clinical judgment when making individual coverage decisions.

Use the most appropriate and current diagnosis and procedure codes when billing.
Provide supporting clinical records when requesting exceptions (e.g., chart notes, prior treatments, measurement of affected BSA).

Denial Risk

Denial risk for exceeding quantity limits or unsupported codes

If the Drug Quantity Management rule is not met at point of service and no supporting clinical documentation or applicable criteria are met, the request or claim may be denied as not covered. Claims billed with non-covered codes or without required documentation may be denied.

Denial risk increases when requested quantities exceed retail 120 g/30 days or home delivery 360 g/90 days without meeting exception criteria.
Appeals should include the clinical evidence that meets one of the listed exception criteria (e.g., >8% BSA or >2 applications/day).

Up to 540 grams per 90 days when exception criteria met

diflorasone 0.05% ointment (generic only) — 120 grams

Product and concentrationdiflorasone 0.05% ointment (generic only)

Default retail limit120 grams per 30 days

Package sizes notedOintment available in 15 g tube (policy lists additional sizes in dosing section)

diflorasone 0.05% ointment (generic only) — 360 grams

Product and concentrationdiflorasone 0.05% ointment (generic only)

Default home delivery limit360 grams per 90 days

Exception maximumUp to 540 grams per 90 days when exception criteria met

diflorasone (cream or ointment) — 180 grams

ApplicabilityCream or ointment formulations of diflorasone (0.05%)

Exception maximum (retail)180 grams per 30 days

Condition for exceptionApproved when patient has FDA‑approved indication and either >8% BSA involvement or needs >2 applications/day

diflorasone (cream or ointment) — 540 grams

ApplicabilityCream or ointment formulations of diflorasone (0.05%)

Exception maximum (home delivery)540 grams per 90 days

Condition for exceptionApproved when patient has FDA‑approved indication and either >8% BSA involvement or needs >2 applications/day