ModifiedCignaPolicy DQM011

Topical Corticosteroids Clobetasol Drug Quantity Management Policy

Quantity limits and exception criteria for topical clobetasol products for Cigna Individual and Family Plans; governs pharmacy dispensing quantities and one-time overrides for additional treatment courses.

Policy Summary

PayerCigna

PolicyTopical Corticosteroids Clobetasol Drug Quantity Management Policy

Policy CodePolicy DQM011

Change TypeNew policy

Effective DateJan 1, 2026

Next Review Date

Key ActionDocument prior dispensed quantity in the relevant lookback period (28 days retail; 84 days home delivery) when requesting a one-time override.

SourceLink

POLICY UPDATE CHANGES

New policy effective 01/01/2026.

50 g/weekmax weekly clobetasol

120 g/28dretail max (cream/gel)

360 g/84dhome delivery max (cream/gel)

+120g / +118mL / +125mL / +138gone-time overrides

28 dretail lookback

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home delivery lookback

Coverage Criteria

Quantity limit exceptions (product-specific)

Exceptions to the standard quantity limits are covered as medically necessary when ONE of the following product-specific criteria is met:

General indication: Patient is using the product for steroid-responsive dermatoses

Required for all exception approvals

Clobetasol emollient cream (generic) additional quantity: If the patient requires an additional 2 weeks of treatment, approve a one-time override for an additional 120 grams at retail or home delivery+120 grams

Retail approval = prior 28-day grams + 120; Home delivery = prior 84-day grams + 120

Clobetasol lotion (Clobex, generic) additional quantity: If the patient requires an additional 2 weeks of treatment, approve a one-time override for an additional 118 mL at retail or home delivery+118 mL

Retail approval = prior 28-day mL + 118; Home delivery = prior 84-day mL + 118

Clobetasol spray (Clobex, generic) additional quantity: If the patient requires an additional 2 weeks of treatment, approve a one-time override for an additional 125 mL at retail or home delivery+125 mL

Retail approval = prior 28-day mL + 125; Home delivery = prior 84-day mL + 125

Impeklo lotion additional quantity: If the patient requires an additional 2 weeks of treatment, approve a one-time override for an additional 138 grams at retail or home delivery+138 grams

Retail approval = prior 28-day grams + 138; Home delivery = prior 84-day grams + 138

One-time override approvals

Covered when prior fill documentation and lookback calculation support need for an additional 2-week supply via one-time override.

Clobetasol spray one-time override: Approve a one-time override for an additional 125 mL when the patient requires an additional 2 weeks of treatment.retail: prior mLs in past 28 days + 125 mL; home delivery: prior mLs in past 84 days + 125 mL

Approval quantity should equal prior amount in lookback period plus the override amount.

Impeklo lotion one-time override: Approve a one-time override for an additional 138 grams when the patient requires an additional 2 weeks of treatment.retail: prior grams in past 28 days + 138 grams; home delivery: prior grams in past 84 days + 138 grams

Approval quantity should equal prior amount in lookback period plus the override amount.

Any exception not listed in the specified criteria (1-4) is considered not medically necessary.

No other one-time override amounts are specified in this policy; approvals are limited to the fixed additional quantities described for each product and do not include alternative or larger override amounts.

Requests that exceed the listed quantity limits for topical clobetasol products without meeting one of the enumerated product-specific exception criteria (items 1–4) are considered not medically necessary and may be denied.

Use beyond the specified one-time override additional quantities — specifically an extra 125 mL for clobetasol spray and an extra 138 grams for Impeklo lotion — is not supported by this section; approvals authorize only the stated one-time amounts added to the member’s prior-fill quantity in the lookback period.

Initial Therapy Criteria

Standard dosing limits

Standard dosing and duration by product

Standard course: Most topical clobetasol products are applied twice daily (BID) for up to 2 consecutive weeks; certain scalp shampoos are applied once daily (QD) for up to 4 weeks. Amounts greater than 50 grams per week should not be used.2 weeks (generally); 4 weeks for certain scalp formulations

For localized moderate-to-severe plaque psoriasis (<10% BSA) an additional 2 weeks (total up to 4) may be considered with caution regarding HPA-axis suppression; if no improvement within 2 weeks, reassess diagnosis.

Retail quantity limits (examples): Typical retail maximum quantities: clobetasol cream/gel/Temovate — 120 grams per 28 days; clobetasol solution — 100 mL per 28 days; Clobex lotion — 118 mL per 28 days; Clobex spray — 125 mL per 28 days; Clobex shampoo — 236 mL per 28 days.See product-specific limits

Coverage limited to quantity sufficient for a 2‑week treatment course per 28 days at maximum recommended weekly doses; additional review required for quantities beyond listed limits.

Quantity Limits by Product

clobetasol emollient cream 0.05% (generic)

Productclobetasol emollient cream 0.05% (generic)

Retail limit120 grams per 28 days

Home Delivery limit360 grams per 84 days

clobetasol gel 0.05% (generic)

Productclobetasol gel 0.05% (generic)

Retail limit120 grams per 28 days

Home Delivery limit360 grams per 84 days

Coding and Lookback Metrics

Covered CPT Codesmixed

No codes listed

Maximum weekly amount

Threshold> 50 grams per week

ContextAmounts greater than 50 grams per week should not be used for topical clobetasol products

Clinical implicationCoverage limited to quantities sufficient for a 2‑week treatment course per 28 days at maximum recommended weekly doses

Retail lookback

Retail lookback period28 days

UseUsed to calculate prior dispensed amount when determining one-time override approvals

Provider Actions and Documentation

Note

Drug Quantity Management Program

Drug Quantity Management point-of-service check — Coverage for clobetasol topical products is determined by Drug Quantity Management criteria at the point of service. Meeting the quantity program criteria does not satisfy other prior authorization or medical necessity requirements; additional prior authorization or coverage criteria may still apply.

Meeting Drug Quantity Management Program criteria does not satisfy any other prior authorization or medical necessity criteria requirements.

Prior Authorization

Exception Prior Authorization Rule

Exception prior authorization rule — Exceptions to listed quantity limits are covered as medically necessary only when ONE of the specified criteria in the policy is met. Any other exception is considered not medically necessary.

Exceptions to quantity limits are covered only when ONE of the listed criteria is met.

Background

Clobetasol propionate is a super-high potency topical corticosteroid indicated for relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, including moderate-to-severe plaque psoriasis. Most topical formulations are applied twice daily and treatment is generally limited to 2 weeks, with limited extensions for some localized or scalp uses as noted in prescribing guidance.

Definitions

Clobetasol propionate

DefinitionClobetasol propionate is a super-high potency topical corticosteroid indicated for corticosteroid-responsive dermatoses and certain formulations indicated for plaque psoriasis.

Indications notedRelief of inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, including plaque psoriasis; age indications vary by formulation.

Typical concentration0.05% formulations referenced throughout the policy

Maximum weekly use

Maximum weekly useAmounts greater than 50 grams per week should not be used for topical clobetasol products.

RationaleRisk of overuse and systemic effects such as HPA axis suppression with extended treatment durations

Step Therapy

Step	Requirement
0	No step therapy requirements specified in this section.

Revision History

2026-01-01policy_createdLatest

Policy created as a new document and made effective 01/01/2026.

Policy Summary

PayerCigna

PolicyTopical Corticosteroids Clobetasol Drug Quantity Management Policy

Policy CodePolicy DQM011

Change TypeNew policy

Effective DateJan 1, 2026

Next Review Date

Key ActionDocument prior dispensed quantity in the relevant lookback period (28 days retail; 84 days home delivery) when requesting a one-time override.

SourceLink

On This Page

Home delivery quantity limits (examples): Typical home delivery maximum quantities: clobetasol cream/gel/Temovate — 360 grams per 84 days; clobetasol solution — 300 mL per 84 days; Clobex lotion — 354 mL per 84 days; Clobex spray — 375 mL per 84 days; Clobex shampoo — 708 mL per 84 days.See product-specific limits

Use lookback periods (retail 28 days; home delivery 84 days) to calculate prior fills when assessing override requests.

clobetasol solution 0.05% (generic)

Productclobetasol solution 0.05% (generic)

Retail limit100 mL per 28 days

Home Delivery limit300 mL per 84 days

Clobex lotion 0.05% (generic)

ProductClobex lotion 0.05% (generic)

Retail limit118 mL per 28 days

Home Delivery limit354 mL per 84 days

Clobex shampoo 0.05% (generic)

ProductClobex shampoo 0.05% (generic)

Retail limit236 mL per 28 days

Home Delivery limit708 mL per 84 days

Clobex spray 0.05% (generic)

ProductClobex spray 0.05% (generic)

Retail limit125 mL per 28 days

Home Delivery limit375 mL per 84 days

Impeklo (metered pump) - discontinued

ProductImpeklo (metered pump) - discontinued listings

Package sizes68 g; 136 g; 408 g (metered pump) — 138 pumps per 68 g bottle

Discontinuation noteProduct listed as discontinued

One-time overrideAdditional 138 grams (one-time) to cover extra 2 weeks

Impoyz (clobetasol 0.025%)

ProductImpoyz (clobetasol 0.025%)

Package sizes100 gram tube; examples include 120 g and 360 g

Retail/Home Delivery examplesMaximum example listings up to 360 grams

Olux / Olux-E (foam) 0.05%

ProductOlux / Olux-E (foam) 0.05%

Package sizes50 g can; 100 g can; aggregated examples: 100 g and 300 g

Aggregate limitAggregated examples up to 300 grams

Temovate (cream/ointment) 0.05%

ProductTemovate (cream/ointment) 0.05%

Retail limit (example)120 grams per 28 days

Home Delivery limit (example)360 grams per 84 days

Clobetasol spray (one-time override)

ProductClobetasol spray (Clobex, generic)

One-time overrideAdditional 125 mL (one-time) to cover extra 2 weeks

Retail/Home Delivery calculationApproval = prior mLs in lookback period + 125 mL

Impeklo lotion (one-time override)

ProductImpeklo lotion

One-time overrideAdditional 138 grams (one-time) to cover extra 2 weeks

Retail/Home Delivery calculationApproval = prior grams in lookback period + 138 grams

Retail fills for clobetasol products

Home delivery lookback

Home Delivery lookback period84 days

UseUsed to calculate prior dispensed amount when determining one-time override approvals

Applies toHome delivery fills for clobetasol products

Billing Rule

One-time Override Quantity Rule

One-time override quantity rule — One-time override approvals are permitted for specific additional fixed amounts when documentation supports the need. For clobetasol spray (Clobex, generic) approve a one-time override of 125 mL. For Impeklo lotion approve a one-time override of 138 grams. One-time approvals are provided for 30 days in duration.

Clobetasol spray: one-time override = +125 mL (add to prior fills in lookback period).
Impeklo lotion: one-time override = +138 grams (add to prior fills in lookback period).
One-time approvals are for 30 days.

Documentation Required

Documentation Expectations

Documentation expectations — Provide an appropriate diagnosis and supporting documentation consistent with the Coverage Policy and the customer's benefit plan; include applicable billing codes. Documentation should support the medical necessity claim.

Include appropriate diagnosis and billing codes consistent with the Coverage Policy and the customer's benefit plan.
Documentation must support the medical necessity claim.

Documentation Required

Documentation of Prior Fills

Documentation of prior fills — Providers must document the quantity dispensed in the relevant lookback period to calculate the approval quantity: retail lookback = 28 days; home delivery lookback = 84 days. The approval quantity equals prior mLs/grams in the lookback period plus any applicable one-time override amount.

Retail lookback period: 28 days.
Home delivery lookback period: 84 days.
Approval quantity = prior dispensed amount in lookback period + one-time override (if applicable).

Denial Risk

Coding and Claim Denial Risk

Coding and claim denial risk — Claims submitted for services that are not accompanied by covered codes under the applicable Coverage Policy will be denied as not covered. When billing, providers must use the most appropriate codes as of the date of submission.

Claims without covered diagnosis/procedure codes under this Coverage Policy will be denied as not covered.
Use the most appropriate codes as of the effective date of submission.

Denial Risk

Quantity Exceedance May Trigger Denial

Quantity exceedance may trigger denial — Requests exceeding the calculated approval quantity (prior mLs/grams in the lookback period plus any one-time override amount) may be denied. Approvals should not exceed the specified maximums for retail (per 28 days) or home delivery (per 84 days) unless an approved exception applies.

Requests exceeding prior dispensed amount in lookback period plus one-time override may be denied.
Approvals should adhere to retail and home delivery maximums unless an approved exception exists.

Note

Provider Action

Provider action — None specified.

Policy consequenceCoverage limited to quantities consistent with recommended weekly maximums

One-time override

One-time overrideAn authorization to dispense an additional specified fixed quantity beyond prior fills to cover an extra 2 weeks of treatment.

ExamplesClobetasol spray +125 mL; Impeklo lotion +138 grams; clobetasol emollient cream +120 grams; Clobex lotion +118 mL

CalculationApproval quantity = prior dispensed amount in lookback period (retail 28 days; home delivery 84 days) plus the specified override amount