CurrentCignaPolicy CNF075

Topical Acne – Kits Step Therapy Policy- (CNF075)

Defines a step therapy program for topical acne kits (Clindacin ETZ and Clindacin PAC) administered by Cigna companies, requiring trial of Step 1 prescription topical acne product and Step 1 prescription acne cleanser prior to coverage of Step 2 kits; approvals are for 1 year.

Policy Summary

PayerCigna

PolicyTopical Acne – Kits Step Therapy Policy- (CNF075)

Policy CodePolicy CNF075

Change TypeClarified; Removed; Revised

Effective Date

Next Review Date

Key ActionDocument that the patient tried one prescription topical acne product and one prescription acne cleanser (products and dates) to meet step therapy criteria for Step 2 kit approval.

SourceLink

POLICY UPDATE CHANGES

Added note defining topical acne kit as kit containing a prescription topical antibiotic.

Clindavix Kit (clindamycin phosphate topical solution 1% and Dynashield) removed from Step 2 as obsolete for >3 years.

Annual revisions with no criteria changes noted (12/18/2024, 12/03/2025, 04/08/2026).

2Step 2 kit products listed

1Required topical product trials (Step 1)

1Required cleanser trials (Step 1)

Scope: Defines a step therapy program for topical acne kits (Step 2 products: Clindacin ETZ and Clindacin PAC) administered by Cigna companies, requiring documented trial of one Step 1 prescription topical acne product and one Step 1 prescription acne cleanser prior to coverage of Step 2 kits; approvals are provided for 1 year.

Coverage stance: Covered with criteria — Step 2 topical acne kits (Clindacin ETZ, Clindacin PAC) are covered when the Step Therapy criteria are met (patient has tried one prescription topical acne product and one prescription acne cleanser); the policy lists 2 Step 2 kit products.

Policy stats

Step 2 kit products listed2

Required prescription topical product trials (Step 1)1

Required prescription cleanser trials (Step 1)1

Step Therapy Criteria (Medically Necessary Coverage)

Topical Acne - Kits Step Therapy Policy product(s) is(are) covered as medically necessary when the following step therapy criteria is(are) met. Any other exception is considered not medically necessary.

ALL of the following

Trial of one Step 1 prescription topical acne product: Patient has tried one prescription topical acne product (Step 1).
Step 1 products include brand or generic topical adapalene, azelaic acid, benzoyl peroxide, clindamycin, dapsone, sulfacetamide or sulfacetamide/sulfur-containing products; see Appendix A examples.
Trial of one Step 1 prescription acne cleanser: Patient has tried one prescription acne cleanser (Step 1).
Step 1 cleansers include brand or generic topical benzoyl peroxide- or sulfacetamide/sulfur-containing cleanser products; see Appendix A examples.

Codes and Examples

Step 2 Products (covered with criteria)mixedCovered

	Clindacin ETZ Kit (clindamycin phosphate 1% pledget and Acuwash cleanser - Medimetriks)
	Clindacin PAC Kit (clindamycin phosphate 1% pledget and Acuwash cleanser - Medimetriks)

Examples of Step 1 Prescription Topical Acne Productsmixed

	Adapalene (e.g., Differin)
	Azelaic acid (e.g., Azelex)
	Benzoyl peroxide (e.g., Inova Easy Pad)
	Benzoyl peroxide/clindamycin (e.g., Acanya, BenzaClin)
	Benzoyl peroxide/erythromycin (e.g., Benzamycin)
	Benzoyl peroxide/salicylic acid formulations
	Clindamycin phosphate (e.g., Cleocin T, Evoclin)
	Clindamycin/tretinoin (e.g., Veltin, Ziana)
	Dapsone (e.g., Aczone)
	Sulfacetamide (e.g., Klaron)

1–10 of 11

1/2

Examples of Step 1 Prescription Acne Cleansersmixed

	Benzoyl peroxide cleansers (e.g., Pacnex 7% wash, Pacnex HP/LP)
	Sulfacetamide/sulfur cleansers (e.g., Avar, Plexion, Sumadan, Sumaxin variants)

Provider Actions & Authorization

Prior Authorization

Step therapy prior authorization requirement

Coverage for Clindacin ETZ or Clindacin PAC (Step 2) requires documented trial of one Step 1 prescription topical acne product AND one Step 1 prescription acne cleanser before approval; approvals are provided for 1 year.

Approvals provided for 1 year
Affected products: Clindacin ETZ, Clindacin PAC

Documentation Required

Document Step 1 trials

Provider must document that the patient tried one prescription topical acne product and one prescription acne cleanser, including the specific products and the dates of trial, to meet step therapy criteria for Step 2 kit approval.

Required trials: one prescription topical product (e.g., adapalene, azelaic acid, benzoyl peroxide, clindamycin, dapsone, sulfacetamide, or sulfacetamide/sulfur)
Required trial: one prescription acne cleanser (e.g., benzoyl peroxide or sulfacetamide/sulfur cleanser)

Denial Risk

Not medically necessary if step not met

If the Step Therapy rule is not met at the point of service and the criteria are not satisfied, the Step 2 product (Clindacin ETZ or Clindacin PAC) is considered not medically necessary and will be denied.

Background & Evidence

Topical clindamycin kits include clindamycin pledgets together with an Acuwash moisturizing daily cleanser; both Clindacin ETZ and Clindacin PAC contain topical clindamycin pledgets and a bottle of Acuwash cleanser.

Guidelines recommend a multimodal approach to acne therapy and state that topical antibiotics should not be used as monotherapy and should be combined with benzoyl peroxide or topical retinoids. Benzoyl peroxide, unlike topical antibiotics, has not been associated with the development of antibiotic resistance.

Definitions

Evidence

Revision History

12/18/2024revised

Annual Revision — No criteria changes noted; Review Date 12/18/2024.

12/18/2024clarified

Policy Statement updated to add note defining topical acne kit: 'For the purpose of this policy, a topical acne kit is defined as kit containing a prescription topical antibiotic.'

12/18/2024removed

Clindavix Kit (clindamycin phosphate topical solution 1% and Dynashield) removed from Step 2 as obsolete for greater than 3 years. (Material change.)

12/03/2025revised

Annual Revision — No criteria changes noted; Review Date 12/03/2025.

04/08/2026revisedLatest

Early Annual Revision — No criteria changes noted; Review Date 04/08/2026.