CurrentCignaPolicy IP0093

Sarecycline (Seysara) for Acne Vulgaris - Coverage Criteria

Defines medical necessity criteria, authorization duration, and coverage stance for sarecycline (Seysara) for treatment of moderate to severe acne vulgaris for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicySarecycline (Seysara) for Acne Vulgaris - Coverage Criteria

Policy CodePolicy IP0093

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document failure, contraindication, or intolerance to both doxycycline and minocycline.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9minimum patient age for coverage

2 agentsrequired prior trial

12 moauthorization duration

not for infectionsindication limitation

Coverage Criteria for sarecycline (Seysara)

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Age: Patient is 9 years of age or older

Diagnosis: Treatment is for moderate to severe acne vulgaris (inflammatory lesions of non-nodular acne)

Prior therapy: Documented failure, contraindication, or intolerance to BOTH doxycycline (capsule or tablet; monohydrate, hyclate or hyclate ER) AND minocycline (capsule or tablet; immediate-release or extended-release)

Continuation Therapy — Continuation covered when ALL of the following are met

Continuation covered when ALL of the following are met

Policy Summary

PayerCigna

PolicySarecycline (Seysara) for Acne Vulgaris - Coverage Criteria

Policy CodePolicy IP0093

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document failure, contraindication, or intolerance to both doxycycline and minocycline.

SourceLink

On This Page

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Provider Actions, Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial and reauthorization approvals may be granted for up to 12 months when all policy criteria are met.

Initial and reauthorization approvals: up to 12 months

Step Therapy

Step Therapy Requirement

Requires documented failure, contraindication, or intolerance to BOTH doxycycline and minocycline before coverage of sarecycline is allowed.

Step therapy requirement: Failure, contraindication, or intolerance to doxycycline (capsule or tablet — monohydrate, hyclate, or hyclate ER)
Step therapy requirement: Failure, contraindication, or intolerance to minocycline (capsule or tablet — immediate-release or extended-release)

Documentation Required

Required Clinical Documentation

Document patient age and evidence of failure, contraindication, or intolerance to BOTH doxycycline and minocycline.

Document patient age (must be ≥ 9 years)
Document clinical evidence of failure, contraindication, or intolerance to both required comparator agents

Denial Risk

Uses Considered Not Covered

Any use of sarecycline (Seysara) other than treatment of moderate to severe acne vulgaris per the policy criteria is considered experimental, investigational, or unproven and is not covered.

Uses considered not covered: Indications other than moderate to severe acne vulgaris as specified in criteria

Definitions

Sarecycline (Seysara) — key facts and definition

Drug class and definitionSarecycline (Seysara) is a narrow‑spectrum tetracycline antibiotic indicated for inflammatory lesions of non‑nodular moderate to severe acne vulgaris in patients 9 years of age and older.

Minimum patient age for coverage9 years of age or older

Indication limitationsEfficacy beyond 12 weeks and safety beyond 12 months have not been established; use for treatment of infections has not been evaluated.

Clinical roleSystemic tetracycline recommended as first‑line systemic antibiotic for moderate to severe or treatment‑resistant inflammatory acne, typically used in combination with topical agents and for limited duration (3–4 months) per acne guidelines.

Regulatory/label cautionNot evaluated for infections — prescribing should be limited to the approved indication (inflammatory non‑nodular moderate to severe acne vulgaris).

OpenPayer

Sarecycline (Seysara) for Acne Vulgaris - Coverage Criteria

Coverage Criteria for sarecycline (Seysara)

Provider Actions, Prior Authorization and Documentation Requirements

Background

Definitions