CurrentCignaPolicy IP0166

Topical Acne - Non-Retinoid Products

Defines medical necessity, reauthorization, and authorization duration for coverage of select non-retinoid topical acne prescription products (clindamycin-containing, minocycline [Amzeeq], and combination clindamycin/benzoyl peroxide/erythromycin products) for Cigna-administered plans; includes different criteria for Employer Plans and Individual/Family Plans and lists products considered non-covered without exception criteria.

Policy Summary

PayerCigna

PolicyTopical Acne - Non-Retinoid Products

Policy CodePolicy IP0166

Change TypeRemovals and revisions

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must document prior trials, contraindications, or intolerance to specified topical alternatives (per product-specific criteria) when requesting coverage; sample receipt does not satisfy criteria.

POLICY UPDATE CHANGES

Removed Dapsone products (Aczone) medical necessity criteria from this policy.

Employer preferred product table: Removed Onexton preferred product requirements.

Up to 12 monthsInitial/ Reauthorization duration

Multiple product-specific criteriaCovered Indications

IP0166Policy Number

Coverage Summary

Defines medical necessity, reauthorization, and authorization duration for coverage of select non-retinoid topical acne prescription products including clindamycin-containing products, minocycline (Amzeeq), and combination clindamycin/benzoyl peroxide/erythromycin products for Cigna-administered plans (Coverage Policy Number IP0166).

Includes background considerations that some benzoyl peroxide–containing products are available over-the-counter (OTC), product formulations differ (cream/lotions versus gels/foams) and formulation/inactive-ingredient differences may justify use when a significant allergy or serious adverse reaction to the generic/bioequivalent exists.

Product-specific Medical Necessity Criteria

Clindagel (clindamycin phosphate 1% topical gel) - Employer Plans

Clindagel 1% topical gel is considered medically necessary when BOTH of the following are documented:

ALL of the following

Trial of clindamycin phosphate 1% topical gel (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction
ALL of the following
- dapsone 5% topical gel
- erythromycin 2% topical gel

Amzeeq (minocycline 4% topical foam) - Employer Plans

Amzeeq 4% topical foam is considered medically necessary when there is documentation of failure, contraindication, or intolerance to BOTH of the following:

ALL of the following

ONE topical clindamycin-containing product (e.g., clindamycin topical antibiotic [various formulations], clindamycin/benzoyl peroxide 1%/5% gel, clindamycin/tretinoin 1.2%/0.025% gel [may require prior authorization])
ONE topical erythromycin-containing product (e.g., erythromycin topical antibiotic [various formulations], erythromycin/benzoyl peroxide 3%/5% gel)

Acanya (clindamycin phosphate/benzoyl peroxide 1.2%/2.5% gel) - Employer Plans

Acanya 1.2%/2.5% topical gel is considered medically necessary when BOTH of the following are documented:

ALL of the following

Trial of clindamycin 1.2%/benzoyl peroxide 2.5% topical gel (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction
ALL of the following
- topical benzoyl peroxide (4% or 8% gel) with topical clindamycin (1% gel) concurrently
- benzoyl peroxide 5%/erythromycin 3% topical gel

BenzaClin (clindamycin phosphate/benzoyl peroxide 1%/5% gel) - Employer Plans

BenzaClin 1%/5% topical gel is considered medically necessary when BOTH of the following are documented:

ALL of the following

Trial of clindamycin 1%/benzoyl peroxide 5% topical gel (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction
ALL of the following
- topical benzoyl peroxide (4% or 8% gel) with topical clindamycin (1% gel) concurrently
- benzoyl peroxide 5%/erythromycin 3% topical gel

Clindamycin phosphate/benzoyl peroxide 1.2%/3.75% topical gel - Employer Plans

Clindamycin phosphate/benzoyl peroxide 1.2%/3.75% topical gel is considered medically necessary when there is documentation of failure, contraindication, or intolerance to ONE of the following:

ANY of the following

clindamycin 5%/benzoyl peroxide 1.2% topical gel
clindamycin 1%/benzoyl peroxide 5% topical gel

Neuac Kit (clindamycin phosphate/benzoyl peroxide 1.2%/5% gel) - Employer Plans

Neuac Kit is considered medically necessary when there is documentation of failure, contraindication, or intolerance to ALL of the following:

ALL of the following

Neuac gel
topical benzoyl peroxide (4% or 8% gel) with topical clindamycin (1% gel) concurrently
benzoyl peroxide/erythromycin 5%/3% topical gel

Clindamycin phosphate/benzoyl peroxide 1.2%/3.75% topical gel - Individual and Family Plans

Considered medically necessary when there is documentation of failure, contraindication, or intolerance to ONE of the following:

ANY of the following

clindamycin 5%/benzoyl peroxide 1.2% topical gel
clindamycin 1%/benzoyl peroxide 5% topical gel

Onexton (clindamycin phosphate/benzoyl peroxide 1.2%/3.75% gel) - Individual and Family Plans

Onexton 1.2%/3.75% topical gel is considered medically necessary when there is documentation of failure, contraindication, or intolerance to ONE of the following:

ANY of the following

clindamycin 5%/benzoyl peroxide 1.2% topical gel
clindamycin 1%/benzoyl peroxide 5% topical gel

Reauthorization Criteria

Continuation (reauthorization) is considered medically necessary when:

ALL of the following

The above medical necessity criteria are met
There is documentation of beneficial response

Provider Actions & Billing Guidance

Prior Authorization

Coverage requires documentation of trials/ failures

Providers must document prior trials, contraindications, or intolerance to the specified topical alternatives listed in the product-specific medical necessity criteria when requesting coverage. Receipt of a sample product does not satisfy criteria for coverage.

Document product-specific trials as listed in medical necessity criteria.

Documentation Required

Beneficial response for reauthorization

For reauthorization, providers must document a beneficial clinical response to the requested non-retinoid topical acne product.

Billing Rule

Use appropriate diagnosis/procedure codes

When billing, providers must use the most appropriate diagnosis and procedure codes as of the date of service. Claims submitted without covered diagnosis/procedure codes under this policy will be denied as not covered.

Claims without covered diagnosis/procedure codes under this policy will be denied as not covered.

Background and Clinical Context

This policy governs formulary exception medical necessity review for select non-retinoid topical acne prescription products, including clindamycin-containing products (e.g., Clindagel), minocycline topical foam (Amzeeq), and combination clindamycin/benzoyl peroxide products (e.g., Acanya, BenzaClin, Neuac, Onexton) as non-covered products subject to exception criteria.

Some benzoyl peroxide–containing products are available over-the-counter (OTC) and are generally indicated for treatment or prevention of mild to moderate acne vulgaris. Topical products are available in multiple formulations (creams/lotions for dry or sensitive skin; gels/foams for oily skin), and formulation differences in inactive ingredients may be relevant when a patient has an allergy or intolerance.

Clinical guidance recognizes the combination of a topical retinoid plus benzoyl peroxide as the preferred approach for most patients with acne, and the policy notes that acne treatment decisions should focus on preventing microcomedones and minimizing visible lesions. Revision history reflects removal of dapsone (Aczone) criteria and employer table updates.

Policy Summary

PayerCigna

PolicyTopical Acne - Non-Retinoid Products

Policy CodePolicy IP0166

Change TypeRemovals and revisions

Effective DateSep 1, 2025

Next Review Date

On This Page

OpenPayer

Topical Acne - Non-Retinoid Products

Coverage Summary

Product-specific Medical Necessity Criteria

Policy Identifiers and Codes

Provider Actions & Billing Guidance

Background and Clinical Context

Revision History