- Quantity Limit: Limit 45gms pe month;QL(1.5gm daily)
- unspecified ST criteria Step Therapy Exists in PA
- Step Therapy: unspecified ST criteria Step Therapy Exists in PA
- Prior Authorization: Derm: Acne Vulgaris:
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 plan year
Reauthorization Required: Yes
- 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
- 1. FDA Approved Indications: A. For the topical treatment of acne vulgaris. 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.
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