JUBLIA (efinaconazole)

JUBLIA (efinaconazole)

SELF ADMINISTRATION - TOPICAL

Indications for Prior Authorization:

• Treatment of onychomycosis (tinea unguium) of the toenails due to Trichophyton rubrum or Trichophyton mentagrophytes.

Coverage criteria:

• Medical record documentation confirms onychomycosis is medically necessary and not cosmetic in nature, AND

• Treatment failure of at least one oral antifungal for onychomycosis (i.e. terbinafine, itraconazole, or alternative azole) AND ciclopirox nail lacquer 8% topical solution.

Dosing:

• Apply one drop of Jublia onto the affected toenail once daily for 48 weeks. For the big toenail, a second drop may be necessary.

Coverage Duration:

• 48 weeks

Authorization is Not Covered for the Following:

• Non-FDA approved indications that are not listed in this policy do not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics Committee.

• Cosmetic treatment of onychomycosis.