CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization — Topical Retinoid Products

This policy governs prior authorization/notification requirements for topical retinoid products under the UnitedHealthcare Pharmacy Clinical Pharmacy Programs and affects prescribers and pharmacy adjudication for covered members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization — Topical Retinoid Products

Policy CodePolicy N/A

Change TypeBrand list updateautomated adjudication clarified

Effective DateJan 1, 2026

Next Review DateOct 1, 2025

Key ActionSubmit prior authorization for topical retinoids unless the member is under 30, in which case covered medications auto-adjudicate.

SourceLink

POLICY UPDATE CHANGES

Updated references and removed Aklief from the typically-excluded list.

Clarified that if members are younger than 30 years of age the topical retinoid prescription will automatically adjudicate without a coverage review.

1/1/2026policy effective date

Age <30automated approval rule

12 moauthorization duration

2025 P 1089-14program identifier

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Coverage Criteria for Topical Retinoid Products

Initial approval criteria

Covered when ALL of the following are met

Topical retinoid approval criteria: 1) Member has a non-cosmetic medical condition listed in the policy (examples include acne vulgaris, psoriasis, actinic keratosis, and other dermatologic conditions enumerated in the policy). 2) Medication is not being requested solely for cosmetic purposes (e.g., photoaging, wrinkling, hyperpigmentation, sun damage, melasma).

See policy condition list for full enumeration

Requests for topical retinoid products will be denied when the medication is requested solely for cosmetic purposes. Examples of cosmetic uses that are excluded from coverage include photoaging, wrinkling, hyperpigmentation, sun damage, and melasma.

Certain branded topical retinoid products are identified in the policy as typically excluded from coverage. These products include Altreno, Arazlo, Avita, Atralin, Retin-A gel, Retin-A cream (brand only), Retin-A Micro, Differin, and Fabior.

Provider Actions, Authorization, and Documentation Requirements

Prior Authorization

Prior authorization required

Prior Authorization/Notification is required for topical retinoid products. Prescriptions for covered topical retinoids will automatically adjudicate for members younger than 30 years of age without a coverage review.

Applies to topical retinoid products (see policy drug list).
Automatic adjudication for members < 30 years old for covered medications.

Billing Rule

Utilization management note

Supply limits and other utilization management programs (including automated approval based on claim history or diagnosis codes) may apply. Some branded topical retinoids are typically excluded from coverage.

Automated approvals may be based on prior claim/medication history, ICD-10 diagnosis codes, and claim logic.
Supply limits may be enforced.
Examples of typically excluded brands: Altreno, Arazlo, Avita, Atralin, Retin-A (brand), Retin-A Micro, Differin, Fabior.

Documentation Required

Medical diagnosis documentation

Documentation submitted with the request must support a non-cosmetic medical diagnosis listed in the policy (e.g., acne vulgaris, psoriasis, actinic keratosis, hidradenitis suppurativa, keratosis, various ichthyoses, etc.).

Provide clinical documentation that establishes a covered medical diagnosis from the policy's listed conditions.
Include relevant ICD-10 diagnosis code(s) and clinical notes demonstrating medical necessity (not cosmetic use).

Denial Risk

Cosmetic use exclusion

Requests may be denied if the medication is requested solely for cosmetic purposes.

Cosmetic indications include photoaging, wrinkling, hyperpigmentation, sun damage, and melasma.
Prior authorization will verify that use is for a covered medical condition; cosmetic use is not a covered benefit.

Initial Therapy Requirements

Initial therapy

Initial approval requires documented medical diagnosis and non-cosmetic use

Initial therapy criteria: 1) Documented non-cosmetic medical condition listed in the policy (examples include acne vulgaris, psoriasis, precancerous lesions, actinic keratosis, and other listed keratinization and skin disorders). 2) Medication is not requested solely for cosmetic purposes (e.g., photoaging, wrinkling, hyperpigmentation, sun damage, melasma).

Members younger than 30 years may auto-adjudicate for covered medications per program rules

Reauthorization / Continuation Criteria

Reauthorization

Reauthorization duration: Authorization will be issued for 12 months.12 months

State mandates and member-specific benefit plans may affect coverage

Step Therapy and Automated Approvals

Step	Operational details
1	Use of automated approval and re-approval may be based on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic; automated processes vary by program or therapeutic class. Supply limits may be imposed.

Definitions and Key Terms

Non-cosmetic medical condition

DefinitionA diagnosis listed in this policy that justifies medical (non-cosmetic) use of topical retinoids (examples: acne vulgaris, psoriasis, precancerous skin lesions/actinic keratoses and other dermatologic conditions).

PurposeDistinguishes medically indicated uses from cosmetic indications (e.g., photoaging, wrinkling, hyperpigmentation, sun damage, melasma) which are excluded from coverage.

Documentation requirementProvider must document a non-cosmetic medical diagnosis from the policy (examples include acne vulgaris, psoriasis, actinic keratosis) to support coverage.

Automated adjudication noteFor covered topical retinoid medications, prescriptions for members younger than 30 years will automatically adjudicate without a coverage review.

Coverage implicationIf the medication is requested solely for a cosmetic purpose, the request may be denied per the policy and UnitedHealthcare pharmacy rider.

Background

Topical retinoids are used for both medical and cosmetic indications. Clinically relevant medical dermatologic uses include conditions such as acne vulgaris, psoriasis, and precancerous skin lesions (e.g., actinic keratoses). Because cosmetic use is not a covered benefit under the pharmacy rider, prior authorization/notification verifies the medication is being used to treat a documented medical condition rather than for cosmetic purposes. The program also notes that supply limits and automated adjudication based on claims or diagnosis codes may apply, and that prescriptions for covered medications will automatically adjudicate for members younger than 30 years.