- Step Therapy: Derm: Acne Vulgaris:
ST Multiple Generics
- Derm: Acne Vulgaris:
Age Requirement: >= 9
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Limited to non-cosmetic use: No
Supporting Documentation Requirements: Chart Notes
- Prior Authorization: Derm: Acne Vulgaris:
Documented Diagnosis: Yes
Age Requirement: >= 9
Duration: 3 Month(s)
Reauthorization Required: Yes
- 1. FDA Approved Indications: A. Aczone Gel 5%: For the topical treatment of acne vulgaris. B. Aczone Gel 7.5%: For the topical treatment of acne vulgaris in patients 12 years of age and older. 2. Health Net Approved Indications and Usage Guidelines: A. For topical application in the treatment of acne vulgaris; AND B. Failure or clinically significant adverse effects to two preferred topical anti-acne agents (e.g., topical adapalene, tretinoin, benzoyl peroxide-erythromycin, clindamycin, benzoyl peroxide-clindamycin phosphate, erythromycin, sulfacetamide-sulfur). 3. Coverage is Not Authorized For: Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature. 3. Authorization Limit: Length of Benefit.
- unspecified ST criteria Step Therapy Exists in PA
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