CurrentCignaPolicy N/A

Topical Antibiotics for Acne - Clindamycin DQM Policy - Per Days

Defines retail and home-delivery maximum quantities and approval criteria for topical clindamycin products (gels, lotion, solution, foam) for acne treatment across Cigna-administered health benefit plans. Applies when Drug Quantity Management rule is not met at point of service; approvals are for 1 year.

Policy Summary

PayerCigna

PolicyTopical Antibiotics for Acne - Clindamycin DQM Policy - Per Days

Policy CodePolicy N/A

Change TypeClarified / Revised / Removed / Annual review

Effective Date

Next Review Date

Key ActionProvider must document that the patient needs treatment for acne affecting greater than 8% body surface area to justify quantities above the standard maximums.

POLICY UPDATE CHANGES

Policy updated to reflect existing quantity limits when a product is obtained via home delivery.

Policy updated to reflect availability of brand Cleocin T 1%.

Brand Cleocin T 1% gel removed from policy (product obsolete) previously.

Annual revision with no criteria changes.

5Products listed

8% BSABSA threshold for overrides

1 yearApproval duration

Policy summary

Topical clindamycin 1% formulations (gel, lotion, solution, foam) are indicated for acne vulgaris. This reimbursement rule is intended to prevent stockpiling, misuse, and overuse by setting retail and home-delivery quantity limits tied to estimated body surface area (BSA) treated and dosing frequency. Limits and override criteria reference an 8% BSA threshold and product-specific per-30-day and per-90-day maxima. This policy applies to Cigna-administered health benefit plans and is used when the Drug Quantity Management rule is not met at the point of service.

Coverage criteria and medically necessary overrides

Medically Necessary Quantity Overrides

Topical clindamycin products are covered as medically necessary when the following criteria are met. Any other exception is considered not medically necessary.

Body surface area criterion: Patient needs to treat acne on greater than 8% of their body surface area> 8% of body surface area
If met, approve requested quantity not to exceed specified product limits

Supporting information: One FTU ≈ 0.5 g treats ≈2% adult BSA; 120 g covers ≈8% BSA when applied twice daily for 30 days

Product-specific approval limits (when >8% BSA)

Products

Clindamycin phosphate 1% lotion (Cleocin T, generic) - twice daily application: Clindamycin phosphate 1% lotion (Cleocin T, generic)Retail: up to 240 mL per 30 days; Home delivery: up to 720 mL per 90 days
Approve requested quantity, not to exceed specified limits
Clindamycin phosphate 1% gel (generic to formerly available Cleocin T gel) - twice daily application: Clindamycin phosphate 1% gel (generic to formerly available Cleocin T gel)Retail: up to 240 grams per 30 days; Home delivery: up to 720 grams per 90 days
Approve requested quantity, not to exceed specified limits
Clindamycin phosphate 1% solution (generic to formerly available Cleocin T solution) - twice daily application: Clindamycin phosphate 1% solution (generic to formerly available Cleocin T solution)Retail: up to 240 mL per 30 days; Home delivery: up to 720 mL per 90 days
Approve requested quantity, not to exceed specified limits
Clindamycin phosphate 1% gel (Clindagel, generic) - once daily application: Clindamycin phosphate 1% gel (Clindagel, generic)Retail: up to 300 mL per 30 days; Home delivery: up to 900 mL per 90 days
Approve requested quantity, not to exceed specified limits
Clindamycin phosphate 1% foam (Evoclin, generic)Retail: up to 200 grams per 30 days; Home delivery: up to 600 grams per 90 days
Approve requested quantity, not to exceed specified limits

Dosing note: Gel/lotion/solution generally twice daily; Clindagel once daily; Evoclin once daily

Package sizes vary (see policy) and retail/home-delivery maxima mirror 30-day multiples

Product list (codes / identifiers)

Product list (no specific billing codes provided)mixed

Cleocin T (clindamycin phosphate 1% topical lotion)	Brand/topical lotion; generic available; 60 mL bottle
Clindagel (clindamycin 1% topical gel)	Brand/topical gel; generic available; 75 mL bottle (also 150 mL and 450 mL home delivery multiples)
Clindamycin 1% topical gel (generic)	Generic gel; supplied as 30 g and 60 g tubes
Clindamycin 1% topical lotion (generic)	Generic lotion; 60 mL bottle
Clindamycin 1% topical solution (generic)	Generic solution; 30 mL and 60 mL bottles and carton of 60 single-use pledget applicators (10 mg/mL)
Evoclin (clindamycin phosphate 1% topical foam)	Brand/topical foam; generic available; 50 g and 100 g aerosol cans

Billing, documentation, and enforcement actions

Documentation Required

Document BSA affected

Provider must document that the patient needs treatment for acne affecting greater than 8% body surface area to justify quantities above the standard maximums.

Threshold: > 8% BSA
Documentation justifies quantities above standard maximums.

Billing Rule

Quantity limit enforcement at point of service

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the criteria; approvals when criteria are met are provided for 1 year. The Drug Quantity Management rule is enforced at point of service and the Drug Quantity Management rule applies to these topical clindamycin products.

Approvals when criteria met are provided for 1 year
Drug Quantity Management rule applies at point of service

Denial Risk

Not medically necessary for other exceptions

Any exception not meeting the specified criteria (including compounded formulations) is considered not medically necessary and additional quantities are not recommended.

Compounded formulations are not recommended/considered not medically necessary
Other exceptions not meeting criteria are considered not medically necessary

Policy revision timeline

2025-02-07revisedLatest

Annual Revision, No criteria changes.

2024-02-08removed

Brand Cleocin T 1% gel removed from the policy (product obsolete); generic clindamycin 1% gel remains with no changes to quantity limits or override criteria.

2023-02-01clarified

Policy updated to reflect existing quantity limits when a product is obtained via home delivery (home delivery maximums mirror retail multiples).

revised