Download ALCORTIN (hydrocortisone/iodoquinol) PRIOR

BLUE CROSS OF NORTHEASTERN PENNSYLVANIA
UTILIZATION MANAGEMENT CRITERIA
MANUAL: PHARMACY UTILIZATION
MANAGEMENT CRITERIA
REFERENCE NO.:
UMC-530-0235
[ ] PROPOSED [ X ] FINAL
Original Development Date
Revision Date
Original Effective Date
Review Date
SECTION:
PHARMACY MANAGEMENT DEPARTMENT
SUBJECT: ALCORTIN A
(HYDROCORTISONE/IODOQUINOL) PRIOR
AUTHORIZATION CRITERIA
December 2, 2015
December 2, 2015
ALCORTIN (hydrocortisone/iodoquinol)
PRIOR AUTHORIZATION CRITERIA
Agents addressed in this policy:
Alcortin A
FDA Approved Indication(s)

Alcortin A (hydrocortisone/iodoquinol) is used to treat a variety of skin conditions such as dermatitis,
skin and skin structure infections, etc.
Mechanism of Action

Alcortin A (hydrocortisone/iodoquinol) is combination product containing iodoquinol which an antibiotic
which prevents the growth of bacteria or fungus and also contain hydrocortisone which is a
corticosteroid that reduces swelling, itching, and redness.
Approval Criteria
For Alcortin A, the following criterion must be met:

The member has tried and failed one formulary topical steroid AND one formulary topical anti-infective
(e.g.mupirocin).
Duration of Authorization:
If approved, a lifetime authorization will be granted.
References:
1. Alcortin. Clinical Pharmacology. Tampa, FL: Gold Standard Multimedia; 2015. Accessed October 6, 2015
Adapted from Highmark J-