Pharmacy Prior Authorization Criteria

Molluscum Contagiosum Agents

Indications for Prior Authorization

Ycanth (cantharidin solution)

• For diagnosis of Molluscum contagiosum
  Indicated for the topical treatment of molluscum contagiosum in adult and pediatric patients 2 years of age and older.

Criteria

Ycanth

Prior Authorization

Length of Approval: 12 Week(s)

• Diagnosis of molluscum contagiosum
AND
• Patient is 2 years of age or older
AND
• Patient has single or multiple, 2- to 5-mm-diameter, flesh-colored to translucent, dome-shaped papules, some with central umbilication [2]
AND
• One of the following [4]:
• Patient has eczema (e.g., atopic dermatitis)
• Patient is immunocompromised
• Patient has extensive involvement or experiences bleeds, secondary infections or discomfort from the lesions
AND
• Lesions have not resolved within six months of diagnosis [4]
AND
• One of the following:
• Patient is treating new lesions that have not previously been treated with Ycanth
OR
• Lesions have previously been treated with Ycanth and will not exceed a total of 4 treatments of Ycanth [A]
AND
• Medication is not being used concurrently with other FDA approved therapies (e.g., Zelsuvmi) on the same lesion for the treatment of molluscum contagiosum [3]
AND
• Prescribed by or in consultation with a dermatologist

P & T Revisions

2024-11-07, 2024-09-20, 2024-07-31, 2023-11-07

References

1. Ycanth Prescribing Information. Verrica Pharmaceuticals Inc. West Chester, PA. July 2023.
2. American Academy of Pediatrics. Molluscum contagiosum. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. 32nd ed. Itasca, IL: American Academy of Pediatrics; 2021: 535-537.
3. Per clinical consult with dermatologist regarding Zelsuvmi, July 31, 2024.
4. Molluscum contagiosum: Diagnosis and treatment. www.aad.org. https://www.aad.org/public/diseases/a-z/molluscum-contagiosum-treatment

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End Notes

1. Subjects' lesions were treated with either YCANTH or vehicle at intervals of approximately 21 days until complete clearance of the lesion or for a maximum of 4 applications

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Revision History

• 2024-11-07: 2024 Annual Review. No criteria changes.
• 2024-09-20: Update to criteria for Ycanth
• 2024-07-31: New criteria for Zelsuvmi. Update to Ycanth criteria for not being used concurrently with Zelsuvmi
• 2023-11-07: New Program for Ycanth

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