CurrentCignaPolicy N/A

Topical Acne - Cleansers Step Therapy Policy

Defines Cigna's step therapy requirements for prescription topical acne cleansers containing benzoyl peroxide or sulfacetamide/sulfur, including which products are Step 1 versus Step 2 and the approval criterion for members under Cigna-administered plans.

Policy Summary

PayerCigna

PolicyTopical Acne - Cleansers Step Therapy Policy

Policy CodePolicy N/A

Change TypeMaterial updates to Step 1 and Step 2 product listings

Effective DateApr 9, 2025

Next Review DateApr 9, 2025

Key ActionIf the patient has tried one Step 1 product, approve a Step 2 product; otherwise coverage for Step 2 is not met.

SourceLink

POLICY UPDATE CHANGES

BenzePrO (benzoyl peroxide 6% Foaming Cloths) and PR Benzoyl Peroxide 7% Wash were added to Step 1.

Step 2 product language was revised to include specific examples of branded and generic sulfacetamide/sulfur and benzoyl peroxide cleansers.

Step 1 Benzoyl Peroxide 6% Foaming Cloths was clarified as BenzePrO (benzoyl peroxide) 6% Foaming Cloths.

3Step 1 named

multipleStep 2 group

1 yrAuth length

04/09/2025Review date

Policy Summary

PayerCigna

PolicyTopical Acne - Cleansers Step Therapy Policy

Policy CodePolicy N/A

Change TypeMaterial updates to Step 1 and Step 2 product listings

Effective DateApr 9, 2025

Next Review DateApr 9, 2025

Key ActionIf the patient has tried one Step 1 product, approve a Step 2 product; otherwise coverage for Step 2 is not met.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Initial Step Therapy Approval

Covered when ALL of the following are met

Step therapy prerequisite: Member has tried one Step 1 product prior to initiating a Step 2 product1 trial of a Step 1 product

Approvals provided for 1 year

Any exception that does not meet the step therapy criteria is considered not medically necessary.

Use of Step 2 topical acne cleansers without a prior trial of a Step 1 product is considered not medically necessary unless the step therapy criteria are met.

Provider Actions & Requirements

Step Therapy

Step therapy prior authorization

This program encourages use of a Step 1 product before a Step 2 product. Step therapy applies at point of service; if the Step Therapy rule is not met for a Step 2 product, coverage will be determined by the Step Therapy criteria. All approvals are for a 1-year duration.

Step 1 examples: BenzePrO (benzoyl peroxide) 6% Foaming Cloths; PR Benzoyl Peroxide 7% Wash; Sulfacetamide Sodium/Sulfur 10%-5% Topical Cleanser
Step 2: Prescription topical acne cleansers containing benzoyl peroxide or sulfacetamide/sulfur (examples: branded products such as Pacnex® 7% Topical Wash, Pacnex® HP/LP Cleansing Pads; Avar™, Avar™ LS; Plexion® Cleanser/Cleansing Pads; Sulfacleanse®; Sumadan® products; various sulfacetamide/sulfur suspensions and washes). This list is not exhaustive.

Step Therapy

Step therapy requirement

If the patient has previously tried one Step 1 product, a Step 2 product should be approved. If the patient has not tried a Step 1 product, coverage for a Step 2 product is not met and is considered not medically necessary.

Billing Rule

Billing and documentation

Providers must bill using the most appropriate diagnosis and procedure codes as of the date the claim is submitted. Reimbursement will only be provided if services are submitted in accordance with the applicable coverage criteria.

Claims submitted for services that are not accompanied by covered diagnosis or procedure code(s) under the applicable coverage policy will be denied as not covered.
Use current, most-appropriate codes as of the effective date of submission.

Denial Risk

Coding/claims risk

Claims submitted without covered diagnosis or procedure codes under the applicable coverage policy will be denied. Services billed for conditions or diagnoses that are not covered under this coverage policy are not eligible for reimbursement.

Providers must ensure submitted codes match the covered indications in the coverage policy.
Failure to submit covered codes will result in denial as not covered.

Definitions

Topical cleanser definition

DefinitionTopical cleanser is defined as a cleanser, solution, liquid, wash, foaming cloth, cleansing cloth, or soap.

ScopeIncludes prescription topical acne cleansers containing benzoyl peroxide or sulfacetamide/sulfur when applying step therapy rules.

Examples (non‑exclusive)Examples of product forms: foaming cloths, topical washes, cleansing pads, suspensions, and soaps listed in the policy.

Policy noteDefinition is used to determine which products are considered for Step 1 vs Step 2 in the Step Therapy program.

OpenPayer

Topical Acne - Cleansers Step Therapy Policy

Coverage Criteria

Provider Actions & Requirements

Definitions

Background