CurrentColorado Rocky Mountain Health PlansPolicy N/A

Cipro HC (ciprofloxacin/hydrocortisone) step therapy coverage criteria

Defines step therapy requirements for coverage of Cipro HC for members under the Essential PDL, requiring trial and failure/intolerance/contraindication to specified lower-cost alternatives before approval.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCipro HC (ciprofloxacin/hydrocortisone) step therapy coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateMay 1, 2025

Key ActionObtain prior authorization and document trial and failure, contraindication, or intolerance to one listed lower-cost alternative.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8/1/2025effective date

12 moauthorization duration

Essential PDLprogram scope

1prior agents required

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage may be subject to external requirements that modify or limit benefits. State mandates and any applicable federal regulatory requirements can alter coverage determinations, and the member’s specific benefit plan may impose additional restrictions. Other internal policies and utilization management programs may also apply and affect coverage for Cipro HC.

Initial Therapy Criteria

Initial therapy

Initial coverage requirement

Initial step therapy: History of failure, contraindication, or intolerance to ONE listed lower-cost alternative must be documented (list reason for therapeutic failure, contraindication, or intolerance)1 agent

Allowed prior agents: (a) ofloxacin otic or ophthalmic formulation administered in the ear; (b) ciprofloxacin otic or ophthalmic formulation administered in the ear

Step Therapy Requirements

Step	Required prior agent (trial and failure, contraindication, or intolerance)	Notes
1	Ofloxacin otic or ophthalmic formulation administered in the ear; OR Ciprofloxacin otic or ophthalmic formulation administered in the ear	Member must have documented history of therapeutic failure, contraindication, or intolerance to ONE of the listed agents. Provider must record reason for failure/intolerance/contraindication. Prior authorization required; approval issued for 12 months.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required per Step Therapy program. Authorization will be issued for 12 months. State mandates, federal regulatory requirements, and the member-specific benefit plan may affect coverage.

Prior authorization duration: 12 months

Step Therapy

Step Therapy Requirement

Member must have a documented history of failure, contraindication, or intolerance to ONE of the listed lower‑cost alternatives before Cipro HC will be approved.

Step required: trial and failure (or contraindication/intolerance) to ONE alternative

Denial Risk

Step Therapy Denial Condition

Coverage will be denied unless the member has a documented history of failure, contraindication, or intolerance to the specified alternatives.

Denial condition: no approval without documented trial/failure or contraindication/intolerance to required alternatives

Documentation Required

Required Documentation

Provider must document the reason for therapeutic failure, contraindication, or intolerance to the alternative tried (specify which alternative: ofloxacin otic/ophthalmic or ciprofloxacin otic/ophthalmic administered in the ear).

Required documentation: clinical reason for failure/contraindication/intolerance and which alternative was tried

Definitions

Therapeutic failure/contraindication/intolerance — definition and notes

DefinitionA documented lack of efficacy, a contraindication, or an adverse reaction/intolerance to a listed alternative medication that justifies use of Cipro HC.

Documentation requiredProvider must list the reason for therapeutic failure, contraindication, or intolerance when requesting coverage for Cipro HC.

Examples of qualifying prior agent outcomesClinical treatment failure (lack of efficacy), documented contraindication to the alternative agent, or intolerable adverse reaction to the alternative agent.

Permitted prior agentsTrial and failure/contraindication/intolerance must be to ONE of: (a) ofloxacin otic or ophthalmic formulation administered in the ear; or (b) ciprofloxacin otic or ophthalmic formulation administered in the ear.

Purpose in step therapyEstablishes clinical justification for bypassing lower-cost alternatives required by the Step Therapy program prior to approval of Cipro HC.

Background

Step Therapy programs are designed to promote the use of lower‑cost, clinically appropriate alternatives before approving higher‑cost agents. For Cipro HC, the program requires that the member have a documented history of failure, contraindication, or intolerance to at least one specified lower‑cost agent (ofloxacin otic/ophthalmic administered in the ear or ciprofloxacin otic/ophthalmic administered in the ear) before prior authorization will be approved.

The intent is to ensure medically necessary use of Cipro HC when first‑line, lower‑cost options are ineffective or not tolerated. Providers must document the clinical reason for trial failure, contraindication, or intolerance as part of the authorization request; prior authorization, when granted, is issued for 12 months.