CurrentCignaPolicy N/A

Tetracyclines (Oral) Step Therapy Policy

Cigna step therapy policy requiring trial of a Step 1 product before coverage of listed Step 2 oral tetracycline antibiotics; applies to health benefit plans administered by Cigna companies. Approvals are for 1 year.

Policy Summary

PayerCigna

PolicyTetracyclines (Oral) Step Therapy Policy

Policy CodePolicy N/A

Change TypeStep 2 product additions / clarifications

Effective DateN/A

Next Review DateN/A

Key ActionDocument prior trial of one Step 1 product to support coverage of Step 2 tetracycline products; approvals are issued for 1 year.

POLICY UPDATE CHANGES

Selected Revision dated 03/05/2025: Minocycline hydrochloride IR tablets (all strengths) were added to Step 2.

Selected Revision dated 03/05/2025: Doxycycline monohydrate 75 mg capsules and doxycycline monohydrate/Mondoxyne 75 mg (generic only) were added to Step 2 in an earlier revision noted in history.

Selected Revision dated 04/24/2024: Generic doxycycline IR-DR capsules were added to Step 2.

Annual Revision dated 02/12/2025: Emrosi ER capsules were added to Step 2.

Early Annual Revision dated 02/28/2024: Tetracycline tablets (all strengths) were added to Step 2.

History note: Annual Revision Review Date 07/26/2023 indicated no criteria changes.

~35Listed Step 2 products/strength entries

1Required Step 1 trials

Summary of changes and key stats

Policy updates add multiple products to Step 2, including material additions: minocycline hydrochloride IR tablets (all strengths), specific doxycycline monohydrate strengths (including 75 mg entries), generic doxycycline IR-DR 40 mg, Emrosi ER 40 mg, and tetracycline tablets (all strengths). The Step 2 product list now includes a broad set of doxycycline, minocycline, demeclocycline and tetracycline brand and generic formulations and strengths as shown in the Step 2 product listings.

Policy key stats

Listed Step 2 products/strength entries~35 entries (multiple tetracycline brand/generic products and strengths listed)

Required Step 1 trials1 prior Step 1 product trial required before Step 2 approval

Approval durationApprovals provided for 12 months (1 year)

07/26/2023Administrative history

Annual Revision Review Date 07/26/2023 indicated no criteria changes.

02/28/202402/28/2024

Early Annual Revision dated 02/28/2024: Tetracycline tablets (all strengths) were added to Step 2. (Added tetracycline tablets to Step 2 list.)

04/24/202404/24/2024

Selected Revision dated 04/24/2024: Generic doxycycline IR-DR capsules were added to Step 2. (Added Doxycycline IR-DR 40 mg capsules to Step 2 list.)

02/12/202502/12/2025

Annual Revision dated 02/12/2025: Emrosi ER capsules were added to Step 2. (Added Emrosi ER 40 mg to Step 2 list.)

03/05/202503/05/2025Latest

Selected Revision dated 03/05/2025: Minocycline hydrochloride IR tablets (all strengths) were added to Step 2. (Also notes earlier addition of doxycycline monohydrate 75 mg and doxycycline monohydrate/Mondoxyne 75 mg generic to Step 2 in history.)

Step therapy coverage determination

Step Therapy Requirements / Medical Necessity

Step 2 products are covered as medically necessary when the following step therapy criteria are met. Any other exception is considered not medically necessary.

Step Therapy Requirements / Medical Necessity: Patient has tried one Step 1 Product

If the patient has tried one Step 1 Product, approve a Step 2 Product.

Approvals are issued for a duration of 1 year. This step therapy policy applies to health benefit plans administered by Cigna companies and requires documentation that the patient has tried one Step 1 product before Step 2 coverage is approved.

Step 2 product coding list

Step 2 products (listed by brand/generic and strengths)mixedCovered

Demeclocycline tablets	Strengths = 150 mg, 300 mg
Doxycycline hyclate tablets	Strengths = 20 mg, 100 mg
Doxycycline hyclate/Morgidox capsules	Strengths = 50 mg, 100 mg
Doxycycline monohydrate capsules/tablets	Strengths = 50 mg, 75 mg (tablets only), 100 mg, 150 mg (tablet only)
Doxycycline monohydrate/Avidoxy tablets	Strengths = 100 mg
Doxycycline monohydrate/Mondoxyne capsules	Strengths = 50 mg, , 100 mg
Doxycycline monohydrate suspension	Strengths = 25 mg/5 ml
Minocycline hydrochloride IR capsules	Strengths = 50 mg, 75 mg, 100mg
Tetracycline hydrochloride capsules	Strengths = 250 mg, 500 mg
Acticlate tablets	Strengths = 75mg, 150 mg (brand and generic)

1–10 of 29

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What clinicians and billing staff must do

Prior Authorization

Step therapy requirement prior to Step 2 coverage

Coverage of Step 2 tetracycline products requires documentation that the patient has tried one Step 1 product; approvals are provided for 1 year.

Documentation Required

Duration of approval documentation

When Step Therapy criteria are met, approvals are issued for a duration of 1 year; document prior trial of Step 1 product in medical record.

Approvals issued for 1 year; document prior trial of Step 1 product in the medical record.

Clinical context and definitions

Tetracyclines (demeclocycline, doxycycline, minocycline, sarecycline, tetracycline) are broad‑spectrum oral antibiotics used for many infections and as adjunctive therapy for acne; some formulations have unique indications (for example, rosacea or adjunct periodontal therapy). The policy encourages use of a Step 1 product prior to using a Step 2 product.

American Academy of Dermatology acne management guidelines (2024) note that tetracyclines are typically the antibiotics used for acne; systemic antibiotics should be used for the shortest possible duration and not as monotherapy, but in conjunction with topical therapy.

Term	Definition
IR
Immediate release
DR
Delayed-release
ER
Extended-release