CurrentCignaPolicy N/A

Topical Corticosteroids - Hydrocortisone Butyrate Drug Quantity Management Policy - Per Days

Defines drug quantity limits and medical-necessity exceptions for topical hydrocortisone butyrate products for Cigna-administered health benefit plans; applies to providers submitting quantity or prior authorization requests.

Policy Summary

PayerCigna

PolicyTopical Corticosteroids - Hydrocortisone Butyrate Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeClarified indicationproduct discontinuations noted

Effective Date

Next Review DateOct 15, 2025

Key ActionIf quantity rules are not met at point of service, submit a prior authorization with supporting diagnosis and documentation; approvals are issued for one year.

SourceLink

POLICY UPDATE CHANGES

Hydrocortisone butyrate lotion approval indication clarified to atopic dermatitis (previously broader corticosteroid-responsive dermatoses).

Brand Locoid Lipocream and Locoid lotion noted as discontinued 4/17/25 in product listings and quantity tables.

120 gretail max for lipocream (base limit)

360 ghome delivery max for lipocream (base limit)

8% BSAbaseline BSA threshold

180 gapproved max cream/ointment (>8% BSA or >BID)

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177 mLapproved max lotion (>8% BSA or >BID)

Coverage and Exception Criteria

Exception criteria by formulation

Approval of additional quantities is recommended if the patient is using the product for an FDA-approved indication and meets one of the following per formulation:

Cream (Locoid Lipocream / generic cream): If the patient needs to treat greater than 8% of body surface area OR administer more frequently than twice daily, approve the quantity requested not to exceed 180 grams per 30 days (retail) or 540 grams per 90 days (home delivery) when the request is for relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.>8% BSA OR >BID

Provides enough to treat >8% BSA BID or 8% BSA TID.

Lotion (Locoid / generic lotion): If the patient needs to treat greater than 8% of body surface area OR administer more frequently than twice daily, approve the quantity requested not to exceed 177 mL per 30 days (retail) or 531 mL per 90 days (home delivery) when the request is for atopic dermatitis.>8% BSA OR >BID

Provides enough to treat >8% BSA BID or 8% BSA TID.

Ointment (generic ointment): If the patient needs to treat greater than 8% of body surface area OR administer more frequently than twice daily, approve the quantity requested not to exceed 180 grams per 30 days (retail) or 540 grams per 90 days (home delivery) when the request is for relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.>8% BSA OR >BID

Provides enough to treat >8% BSA BID or 8% BSA TID.

Solution (generic solution): If the patient needs to treat greater than 8% of body surface area OR administer more frequently than twice daily, approve the quantity requested not to exceed 180 mL per 30 days (retail) or 540 mL per 90 days (home delivery) when the request is for inflammatory manifestations of seborrheic dermatitis.>8% BSA OR >BID

Provides enough to treat >8% BSA BID or 8% BSA TID.

No overrides are recommended for use in compounded formulations. Requests for quantities that exceed the listed Drug Quantity Limits for compounded topical hydrocortisone butyrate should not be approved, as compounded use is explicitly excluded from exception consideration.

Any request for an exception to the quantity limits that does not meet the policy’s listed criteria is considered not medically necessary. The policy states that additional quantities are covered only when the patient is using the product for an FDA‑approved indication and meets one of the specified formulation‑specific criteria; all other exceptions must be denied.

Coding and Definitions

Covered CPT Codesmixed

No codes listed

BSA per FTU

BSA per FTU1 g ≈ 4% body surface area (based on 1 FTU ≈ 0.5 g ≈ 2% BSA)

FTU definition (adult)One FTU = amount squeezed from a standard tube along an adult fingertip ≈ 0.5 g, covers ≈2% adult BSA

Pediatric noteFTU remains the adult fingertip amount; covered BSA will vary by child size

Prior Auth, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Required When Quantity Limits Not Met

If the Drug Quantity Management rule is not met at the point of sale, prior authorization is required and coverage will be determined by the clinical criteria. Providers should submit supporting documentation (diagnosis/procedure codes and clinical notes) with the request. All approvals are provided for 1 year.

All approvals are for 1 year.
Submit applicable diagnosis and procedure codes with clinical documentation demonstrating medical necessity.
If billed with diagnoses not covered by this policy, claims will be denied.

Step Therapy

No step therapy requirements are specified for topical hydrocortisone butyrate under this policy.

Clinical Background

Hydrocortisone butyrate topical formulations are indicated for relief of inflammatory and pruritic manifestations of corticosteroid‑responsive dermatoses; the solution formulation is indicated for seborrheic dermatitis and the lotion is indicated for mild to moderate atopic dermatitis in patients aged ≥3 months. The policy notes typical application frequency of BID–TID for cream, lipocream, ointment and solution, and BID for lotion. When determining quantity needs, providers may reference a fingertip unit (FTU) standard where 1 g ≈ 4% BSA to estimate body surface area treated and justify exceptions when the patient requires treatment of >8% BSA or more frequent than twice daily.

Key Definitions

Fingertip unit (FTU) definition and equivalence

Fingertip unit (FTU)Amount squeezed from a standard tube along an adult fingertip (one FTU) ≈ 0.5 g

Coverage per FTUOne FTU covers an area ≈2% of an adult's total BSA

ConversionTherefore 1 g (≈ two FTUs) provides enough for ≈4% of adult BSA

Recommended Application / Initial Use

Recommended application — typical frequency by formulation

Typical application frequency by formulation.

Dosing: Cream / Lipocream / Ointment / Solution: apply to affected area two times daily (BID) to three times daily (TID). Lotion: apply to affected area two times daily (BID).

Approval Duration and Renewal

Approval duration — approvals are provided for one year

Approvals are provided for one year.

Duration: All approvals issued under this policy are for a 1 year duration.

Product Quantity Limits

Locoid Lipocream / generic cream — 120 grams (retail base)

ProductLocoid Lipocream / hydrocortisone butyrate 0.1% cream (brand discontinued)

Retail base limit120 grams per 30 days

Package sizes notedAvailable in 15 g, 45 g, 60 g tubes (brand listing)

Locoid Lipocream / generic cream — 360 grams (home delivery base)

ProductLocoid Lipocream / hydrocortisone butyrate 0.1% cream (brand discontinued)

Home delivery base limit360 grams per 90 days

Brand status

Policy Summary

PayerCigna

PolicyTopical Corticosteroids - Hydrocortisone Butyrate Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeClarified indicationproduct discontinuations noted

Effective Date

Next Review DateOct 15, 2025

Key ActionIf quantity rules are not met at point of service, submit a prior authorization with supporting diagnosis and documentation; approvals are issued for one year.

SourceLink

On This Page

Documentation Required

Required Documentation for Requests

Requests must include the covered diagnosis/procedure codes and supporting clinical documentation (office notes, prior treatment history, or other records) demonstrating the FDA‑approved indication or other approved reason per the criteria.

Include specific ICD-10 diagnosis code(s).
Include documentation of indication and prior therapies, if applicable.
Provide quantity requested and rationale for exceeding quantity management limits.

Denial Risk

Denial Triggers

Requests or claims lacking a covered diagnosis, required documentation, or not meeting the quantity rule at the point of service may be denied as not covered.

Claims billed with diagnoses that are not covered under this policy will be denied.
Prior authorization requests missing required supporting documentation may be denied.
Requests that do not meet the Drug Quantity Management rule at point of service will require PA; absence of PA or criteria support may result in denial.

Brand discontinued 4/17/25 (listed in product lines)

Hydrocortisone butyrate cream / ointment (generic) — 120 g retail / 360 g HD

ProductHydrocortisone butyrate cream/ointment (generic)

Retail base limit120 grams per 30 days (base retail)

Home delivery base limit360 grams per 90 days (base HD)

Hydrocortisone butyrate lotion (Locoid/generic) — 177 mL (retail base)

ProductHydrocortisone butyrate lotion (Locoid/generic)

Retail base limit177 mL per 30 days

Indication for exceptionApproved for atopic dermatitis when >8% BSA or >BID

Hydrocortisone butyrate lotion (Locoid/generic) — 531 mL (home delivery base)

ProductHydrocortisone butyrate lotion (Locoid/generic)

Home delivery base limit531 mL per 90 days

Exception criteriaQuantity approved when treating >8% BSA or >BID for atopic dermatitis

Hydrocortisone butyrate solution (generic) — 180 mL (retail base)

ProductHydrocortisone butyrate solution (generic)

Retail base limit180 mL per 30 days

Indication for exceptionApproved for inflammatory manifestations of seborrheic dermatitis when >8% BSA or >BID

Hydrocortisone butyrate solution (generic) — 540 mL (home delivery base)

ProductHydrocortisone butyrate solution (generic)

Home delivery base limit540 mL per 90 days

Exception criteriaQuantity approved when treating >8% BSA or >BID for seborrheic dermatitis

Cream / Ointment (when >8% BSA or >BID) — 180 grams (approved max)

ContextCream or ointment used to treat >8% BSA or administered >BID

Approved maximum (retail)180 grams per 30 days

Approved maximum (home delivery)540 grams per 90 days

Cream / Ointment (when >8% BSA or >BID) — 540 grams (approved max for HD)

ContextCream or ointment when >8% BSA or administered >BID

Approved maximum (home delivery)540 grams per 90 days

Retail equivalent180 grams per 30 days corresponds to 540 grams per 90 days