- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Step Therapy Exists in PA
- 1. FDA Approved Indications: a. For the treatment of only inflammatory lesions (papules and pustules) of rosacea in adult patients. 2. Health Net Approved Indications and Usage Guidelines: a. Treatment of inflammatory lesions (papules and pustules) of rosacea in adult patients; AND b. One month failure of or clinically significant adverse effects to immediate-release doxycycline 50mg. 3. Coverage is Not Authorized For: Treatment of non-inflammatory lesions in acne vulgaris or rosacea. 4. Authorization Limit: Length of Benefit.
- Prior Authorization: Derm: Rosacea:
PA Applies
- Derm: Rosacea:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Step Therapy: Derm: Rosacea:
Step Applies
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