CurrentCignaPolicy CNF076

Topical Acne Products Step Therapy Policy - (CNF076)

Defines a step therapy program for topical prescription acne products across Cigna-administered health benefit plans, specifying Step 1 (preferred) and Step 2 (non-preferred/brand or specified generics) product lists, the exception/approval rule, and administrative guidance for coverage decisions.

Policy Summary

PayerCigna

PolicyTopical Acne Products Step Therapy Policy - (CNF076)

Policy CodePolicy CNF076

Change TypeClassifications / additions and administrative updates

Effective Date

Next Review Date

Key ActionRequire documentation that the patient has tried one Step 1 product before approving a Step 2 product; submit supporting documentation when requesting Step 2 coverage.

SourceLink

POLICY UPDATE CHANGES

Clindamycin phosphate 1% foam removed from Step 1 and added to Step 2 (selected revision 01/08/2025).

Generic sodium sulfacetamide-sulfur and related generics moved to Step 2; sodium sulfacetamide/sulfur 10%/5% emollient cream remained in Step 1 (annual revision 03/05/2025).

Plexion TS and generic sulfacetamide sodium/sulfur 10%-5% topical suspension added to Step 2 (selected revision 12/03/2025).

Policy name changed to 'Topical Acne Products Step Therapy Policy' (selected revision 01/08/2025).

Multiple annual reviews with 'No criteria changes' (12/03/2025, 03/18/2026, 04/15/2026).

2Step levels (Step 1 / Step 2)

MultipleProducts listed

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Coverage summary & scope

Defines a step therapy program for topical prescription acne products administered by Cigna Companies that requires trial of a Step 1 (preferred) topical acne product before coverage of a Step 2 (non-preferred brand or specified generics) product; if the Step Therapy rule is not met at point of service, coverage is determined by the Step Therapy criteria. The program lists topical agents (e.g., adapalene, benzoyl peroxide, clindamycin, dapsone, erythromycin, sulfacetamide/sulfur and combination products) and related formulations, and all approvals are provided for 1 year in duration.

Key Facts

Approval duration1 year

Step levels2

Policy numberCNF076

Last review2026-04-15

Coverage stancemixed

Step Therapy Criteria / Approval Rule

Topical Acne Products 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.

Prior trial requirement: Patient has tried one Step 1 Product prior to Step 2 Product
If the patient has tried one Step 1 Product, approve a Step 2 Product. All approvals provided for 1 year in duration.

Approval duration: All approvals provided for 1 year in duration.

Providers must submit supporting documentation of Step 1 product trial when requesting Step 2 coverage.

Product lists (Step 1 / Step 2) and code groups

Listed Step 1 Products (preferred first-line topical prescription products)mixedCovered

sodium sulfacetamide/sulfur 10%/5% emollient cream	Remains Step 1
generic prescription topical adapalene products	adapalene products (generic)
generic prescription topical benzoyl peroxide products	benzoyl peroxide-containing products (other than specified examples moved/obsolete)
generic prescription topical clindamycin products (other than generic Clindagel and clindamycin phosphate 1% foam)	clindamycin-containing products excluding specific generics moved to Step 2
dapsone-containing products (generic)	dapsone products
erythromycin-containing products (generic)	erythromycin products
sodium sulfacetamide-containing products (generic)	sulfacetamide-containing products

Listed Step 2 Products (require prior trial of Step 1 product)mixedExperimental

Aklief	trifarotene 0.005% cream - brand name topical
Amzeeq	minocycline 4% foam - brand
Azelex	azelaic acid 20% cream - brand
Brand adapalene products	e.g., Differin (brand)
Brand benzoyl peroxide products	e.g., Inova Easy Pad (brand examples; some pads noted obsolete)
Brand clindamycin products	e.g., Cleocin T, Evoclin (brand)
Brand dapsone products	e.g., Aczone
Brand erythromycin products	e.g., Erygel
Brand sulfacetamide products	e.g., Klaron
Brand sulfacetamide/sulfur products	e.g., Avar-e, Avar-e LS, Plexion cream/lotion, Plexion TS

1–10 of 28

1/3

Obsolete / Removed from Market notesmixed

Inova Easy Pad (specific pads)	benzoyl peroxide pads noted obsolete 08/14/2023
Avar-e LS (brand)	brand obsolete 09/10/2024

What providers must do

Prior Authorization

Step therapy prior trial requirement

Require documentation that the patient has tried one Step 1 product before approving a Step 2 product; if Step Therapy rule not met at point of service, coverage determined by criteria.

Documentation Required

Approval duration and documentation

All approvals are provided for 1 year in duration; providers must submit supporting documentation of Step 1 product trial when requesting Step 2 coverage.

Approvals are for 1 year; supporting documentation of a Step 1 trial is required.

Policy update changes

01/08/2025clarified

Clindamycin phosphate 1% foam removed from Step 1 and added to Step 2 (selected revision 01/08/2025).

03/05/2025revised

Generic sodium sulfacetamide-sulfur and related generics moved to Step 2; sodium sulfacetamide/sulfur 10%/5% emollient cream remained in Step 1 (annual revision 03/05/2025).

12/03/2025added

Plexion TS and generic sulfacetamide sodium/sulfur 10%-5% topical suspension added to Step 2 (selected revision 12/03/2025).

Clinical context & references

This Step Therapy program encourages use of a Step 1 topical acne product before using a Step 2 product. Topical agents covered include adapalene, benzoyl peroxide, clindamycin, dapsone, erythromycin, sulfacetamide/sulfur, and combination products in formulations such as gels, creams, lotions, solutions/pledgets, pads, foams, and ointments. Clinical guidelines cited do not prefer specific brand name agents over equivalent generics and recommend a multimodal approach; topical antibiotics should not be used as monotherapy and are recommended in combination with benzoyl peroxide or topical retinoids.

Topical acne product: a gel, cream, lotion, solution/pledget, pad, foam, or ointment used topically for acne.

References / Evidence

GuidelineJ Am Acad Dermatol 2024 acne management guidelines

Drug referencesFacts and Comparisons Online 2026; Clinical Pharmacology 2026