CurrentCignaPolicy N/A

POLICY: Topical Acne - Kits Step Therapy Policy

Cigna step therapy policy that requires trial of a Step 1 prescription topical acne product plus a prescription acne cleanser before covering Step 2 acne kits (Clindacin ETZ and Clindacin PAC). Approvals are for one year; exceptions considered not medically necessary.

Policy Summary

PayerCigna

PolicyPOLICY: Topical Acne - Kits Step Therapy Policy

Policy CodePolicy N/A

Change TypeDefinition added; product removed; annual revision

Effective Date

Next Review Date

Key ActionProvider must document prior use of one prescription topical acne product and one prescription acne cleanser when requesting coverage for a Step 2 kit.

POLICY UPDATE CHANGES

Added definition: For the purpose of this policy, a topical acne kit is defined as kit containing a prescription topical antibiotic.

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

Annual revisions with no criteria changes noted for prior years (12/20/2023 and 12/18/2024); 12/03/2025 annual revision recorded.

2Step 2 Kits Covered (examples)

1Required Step 1 topical products to try

1Required Step 1 prescription cleansers to try

Coverage Summary

Cigna covers topical acne kits (Step 2: Clindacin ETZ, Clindacin PAC) when step therapy is met, which requires documentation of trial of one Step 1 prescription topical acne product and one Step 1 prescription acne cleanser. Approvals are provided for 1 year. Other uses are considered not medically necessary.

Quick Facts

Step 2 Kits Covered2

Required Step 1 topical products to try1

Required Step 1 prescription cleansers to try1

Last review2025-12-03

Step Therapy Criteria (Initial / Step 2 Coverage)

Step Therapy Criteria for Topical Acne Kits (Step 2)

Topical Acne - Kits Step Therapy Policy product(s) is(are) covered as medically necessary when ALL of the following step therapy criteria are met. All approvals are provided for 1 year in duration. If the Step Therapy rule is not met for a Step 2 Product at the point of service, coverage will be determined by the Step Therapy criteria below. For the purpose of this policy, a topical acne kit is defined as a kit containing a prescription topical antibiotic.

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

Applicable Products / Example Codes

Products referenced (examples, not exhaustive)mixed

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

Example Step 1 topical products (not cleanser)mixed

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	e.g., Inova Easy Pad 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

Example prescription acne cleansersmixed

benzoyl peroxide wash	e.g., Pacnex 7% wash, Pacnex HP/LP
sulfacetamide/sulfur cleansers	e.g., Avar, Plexion, Sumadan, Sumaxin series (cleanser formulations)

Provider Actions / Prior Authorization

Prior Authorization

Step therapy prior authorization requirement at point of sale

Coverage for Step 2 products requires documentation that the patient has tried one Step 1 prescription topical acne product and one Step 1 prescription acne cleanser; approvals are provided for 1 year.

Approval duration: 1 year

Documentation Required

Document trials of Step 1 products

Provider must document prior use of one prescription topical acne product and one prescription acne cleanser when requesting coverage for a Step 2 kit.

One prescription topical acne product (e.g., adapalene, azelaic acid, benzoyl peroxide, clindamycin, dapsone, sulfacetamide, sulfacetamide/sulfur)
One prescription acne cleanser (e.g., benzoyl peroxide or sulfacetamide/sulfur-containing cleanser)

Clinical Evidence & References

Guidelines recommend against topical antibiotic monotherapy and advise combining topical antibiotics with benzoyl peroxide or topical retinoids; benzoyl peroxide is noted to reduce the risk of antibiotic resistance. The Clindacin ETZ and Clindacin PAC kits combine topical clindamycin pledgets with an Acuwash moisturizing daily cleanser. Relevant evidence includes the J Am Acad Dermatol guideline: J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30, and product labeling for the kits: Clindacin ETZ Kit PI Sep 2022 and Clindacin PAC Kit PI Nov 2022.

Definitions & Appendix

Topical acne kit: For this policy, a topical acne kit is defined as a kit containing a prescription topical antibiotic (for example, clindamycin pledget plus cleanser).

Step 1 topical acne products: Brand or generic topical adapalene, azelaic acid, benzoyl peroxide, clindamycin, dapsone, sulfacetamide or sulfacetamide/sulfur-containing products (examples include adapalene/Differin, azelaic acid/Azelex, benzoyl peroxide/Inova Easy Pad, clindamycin/Cleocin T).

Step 1 prescription acne cleansers: Brand or generic topical benzoyl peroxide or sulfacetamide/sulfur-containing cleansers (examples include Pacnex 7% wash and sulfacetamide/sulfur cleansers such as Avar and Plexion).

The policy encourages trial of a Step 1 topical product plus a Step 1 cleanser prior to Step 2 kits and notes that topical antibiotics should not be used as monotherapy and benzoyl peroxide is recommended to reduce antibiotic resistance.

Revision History

12/03/2025annual_revisionLatest

Annual Revision recorded; no criteria changes noted for this review (12/03/2025).

12/18/2024annual_revision

Annual Revision with summary: No criteria changes.

12/20/2023annual_revision