Topical tretinoin (brand/formulary prior authorization)
This document governs prior authorization requests for topical tretinoin products submitted to OptumRx (Blue Cross Blue Shield - South Carolina) and affects prescribers and pharmacists seeking coverage for branded topical tretinoin formulations.
No material clinical or coverage changes in this revision.
Coverage and Authorization Considerations
Authorization considerations
Coverage consideration requires completed clinical information and prior trial responses; prescriber attestation is required.
See required provider, medication, and clinical information fields on the prior authorization form
Form provides checkboxes for Darier's disease and acne vulgaris and a field to list other diagnoses
Form asks whether the patient tried and failed a generic topical tretinoin and whether the prescriber deems a generic inappropriate
The prior authorization form requires submission of completed provider and member information, medication details, and the prescriber's signature. The clinical section specifically captures the patient's diagnosis (including checkboxes for keratosis follicularis (Darier's disease) and acne vulgaris and a field for other diagnoses) and documents prior treatment with generic topical tretinoin products. These fields must be completed for consideration of coverage.
The form does not include any explicit statements labeling use of topical tretinoin as not medically necessary. No section on the form provides standardized "not medically necessary" language or denial criteria beyond indicating that requests may be denied if required information is missing.
Form Identifier / Codes
| TopicalTretinoins_2019Feb | Internal form identifier / prior authorization form name |
What Providers Must Do
Prior Authorization Required
Prior authorization required for topical tretinoin — use the OptumRx prior authorization form (TopicalTretinoins_2019Feb). Submit the completed form via CoverMyMeds (go.covermymeds.com/OptumRx) or fax to 844-403-1029. For assistance with the prior authorization process, contact OptumRx at 855-811-2218, Monday–Friday, 8 a.m. to [local time].
- Form identifier: TopicalTretinoins_2019Feb
- Fax: 844-403-1029
- CoverMyMeds: go.covermymeds.com/OptumRx
- Help line: 855-811-2218
Generic Product Trial/Medical Appropriateness
The prior authorization form asks whether the patient has tried and failed a generic topical tretinoin product and whether the prescriber deems a generic product inappropriate for the patient. Be sure to answer both questions and provide supporting details if indicating a generic is inappropriate.
- Has the patient tried and failed a generic topical tretinoin product? (Yes/No)
- Does the prescriber deem a generic topical tretinoin product inappropriate? (Yes/No)
Completed Form and Required Information
The completed prior authorization form must include required provider, member, medication, and clinical information. Incomplete submissions may result in denial or delayed review.
- Provider information (required): Provider name, NPI, specialty, office address, phone, fax.
- Member information (required): Member name, insurance ID#, date of birth.
- Medication information (required): Medication name, strength, dosage form, directions for use.
- Clinical information (required): Diagnosis, prior therapies tried/failed, answers to disease-specific questions, prescriber's signature and date.
Denial Risk for Incomplete Submissions
Requests may be denied unless all required information is received. Ensure every required field on the prior authorization form is completed and any supporting clinical details are attached.
- Incomplete forms or missing clinical information can lead to denial.
- Attach any additional comments, diagnoses, symptoms, or medications tried/failed that are relevant to the review.
Background / Indications
This prior authorization form is used to document diagnoses for which topical tretinoin may be prescribed (for example, keratosis follicularis — Darier's disease and acne vulgaris), to record whether the patient has tried and failed a generic topical tretinoin, and to capture whether the prescriber deems a generic formulation inappropriate. The form includes space for additional clinical comments and the prescriber's attestation via signature; the form footer identifies the internal form name as TopicalTretinoins_2019Feb.
Defined Terms
Initial Authorization Requirements
Initial authorization
Initial authorization considerations as captured on the prior authorization form.
Complete clinical information and prescriber attestation are required for initial approval; incomplete submissions may be denied
Step Therapy / Prior Trial Requirements
| Step | Requirement |
|---|---|
| 1 | Must indicate prior trial and failure of a generic topical tretinoin product (Yes/No) |
| If a generic topical tretinoin has not been tried, prescriber must state why a generic would be inappropriate for this patient (Yes/No) |
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