CurrentCignaPolicy N/A
Topical Corticosteroids - Hydrocortisone Butyrate Drug Quantity Management Policy - Per Days
Defines per‑day/per‑30 day and per‑90 day quantity limits and exception criteria for topical hydrocortisone butyrate products (cream/lipocream, lotion, ointment, solution) for Cigna-administered health benefit plans. Approvals for exceptions are for 1 year and intended to allow greater quantities when treating >8% BSA or increased frequency for FDA‑approved indications.
Policy Summary
PayerCigna
PolicyTopical Corticosteroids - Hydrocortisone Butyrate Drug Quantity Management Policy - Per Days
Policy CodePolicy N/A
Change TypeAnnual revision; clarification to lotion indication
Effective Date
Next Review Date
Key ActionIf requested quantity exceeds the Drug Quantity Management standard maximum for the product at point of service, submit an exception request and document FDA‑approved indication plus need to treat >8% BSA or increased administration frequency; approvals are provided for 1 year.
POLICY UPDATE CHANGES
Hydrocortisone butyrate lotion approval indication clarified to atopic dermatitis in a prior annual revision.
Annual revisions listed with no criteria changes for 10/14/2024 review.
4Products covered (cream/lipocream, lotion, ointment, solution)
8% BSAStandard BSA threshold for quantity
180g / 540gMax cream/ointment exception retail / 90‑day home