Pharmacy Prior Authorization Criteria

Halcinonide cream

Indications for Prior Authorization

Halcinonide cream

• For diagnosis of Corticosteroid-responsive dermatoses
  Indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

Criteria

Halcinonide cream

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure, contraindication, or intolerance to three of the following generics:
• betamethasone dipropionate 0.05% ointment
• betamethasone augmented 0.05% cream
• desoximetasone 0.25% cream
• fluocinonide 0.05% solution
• fluocinonide 0.05% cream
• fluocinonide 0.05% gel
• fluocinonide 0.05% ointment

P & T Revisions

2024-03-06, 2023-07-06, 2022-07-07, 2021-07-06

References

1. Halcinonide Prescribing Information. Glasshouse Pharmaceuticals Limited Canada. Ontario, Canada. October 2020.

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Revision History

• 2024-03-06: Annual review: No updates required.
• 2023-07-06: Annual review: No updates required.
• 2022-07-07: Annual review: Updated criteria and background.
• 2021-07-06: new ST program

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