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