Retinoids
Drug - Topical Retinoids for Acne
December 2012
Preferred
- Tretinoin* (gel 0.01%, 0.03% - cream 0.03%, 0.05%, 0.10%)
- Retin-A Micro/Micro pump (gel 0.04%, 0.1%)
- Differin (adapalene) (gel, cream, and lotion)
Nonpreferred
- Retin-A (mac applies) (gel 0.01%, 0.03% - cream 0.03%, 0.05%, 0.10%)
- Avita (0.03% gel and cream) (mac applies)
- Atralin gel (tretinoin) 0.05%
- Adapalene (0.1% gel and cream)
- EpiDuo (adapalene/benzoyl peroxide)
- Tazorac gel (0.05% and 0.1%)
- Tazorac cream (0.05% and 0.1%)
- Veltin (clindamycin/tretinoin)
- Ziana (clindamycin/tretinoin)
*all are generic and generic pricing (mac) has been applied
Criteria for nonpreferred single agent products
- Patient is 12 years of age or older and is not pregnant AND
- Is being treated for moderate to severe acne vulgaris AND
- Has tried at least two of the preferred single agent retinoids with demonstrated compliance without therapeutic benefit
Criteria for nonpreferred combination products (Veltin, Ziana)
- Patient is 12 years of age or older and is not pregnant AND
- Is being treated for moderate to severe acne vulgaris AND
- Has tried at least tretinoin and clindamycin as separate agents at the same time with benefit and tolerability
Criteria for nonpreferred combination products (Epiduo)
- Patient is 12 years of age or older and is not pregnant AND
- Is being treated for moderate to severe acne vulgaris AND
- Has tried at least adapalene and benzoyl peroxide as separate agents at the same time with benefit and tolerability
Tazorac (tazarotene) criteria
- Patient is not pregnant AND
- Tazorac is being used for stable plaque psoriasis of up to 20% body surface area involvement and patient is at least 18 years of age OR
- Tazorac is being used for mild to moderate facial acne and has tried both of the preferred retinoids (tretinoin and adapalene) with demonstrated compliance without therapeutic benefit and patient is at least 12 years of age
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411