- Derm: Acne Vulgaris:
Age Requirement: >= 12
Duration: 1 plan year
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
- Step Therapy: Derm: Acne Vulgaris:
ST Single Generic
- Prior Authorization: Derm: Acne Vulgaris:
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 plan year
Reauthorization Required: Yes
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