harvard pilgrim acne rosacea prior auth Policy | OpenPayer

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harvard pilgrim acne rosacea prior auth Policy | OpenPayer

Coverage Criteria for Acne and Rosacea Medications

General coverage rule

The plan may authorize coverage of products used for acne and rosacea for Members, when ALL of the following criteria are met:

General: Coverage requires meeting the specific product-level criteria listed below

See individual product entries

Adapalene

Covered when ALL of the following are met:

Adapalene criterion: The Member had an insufficient response to therapy with tretinoin

Alitretinoin (Panretin)

Covered when ALL of the following are met:

Diagnosis: Documented diagnosis of AIDS-related Kaposi's sarcoma

Systemic therapy not required: Documentation the Member does not require systemic anti-Kaposi's sarcoma therapy

Azelaic Acid Foam (Finacea)

Covered when ALL of the following are met:

Diagnosis: Documented diagnosis of rosacea

Prior therapy: An inadequate response or intolerance to generic metronidazole gel and at least one additional generic topical agent used for the treatment of rosacea

Azelaic Acid Cream (Azelex)

Covered when ALL of the following are met:

Diagnosis: Documented diagnosis of acne

Prior therapy: An inadequate response to therapy with tretinoin

Benzoyl peroxide

Covered when ALL of the following are met:

Prior therapy: The Member had an insufficient response to therapy with two of the preferred benzoyl peroxide products

Brimonidine Gel (Mirvaso)

Covered when ALL of the following are met:

Age and diagnosis: The Member is at least 18 years of age with the diagnosis of persistent (nontransient) erythema of rosacea

Prior therapy: The Member had an insufficient response to at least two alternative generic topical products, e.g. metronidazole, sulfacetamide, retinoid, clindamycin

Clascoterone Cream (Winlevi)

Covered when ALL of the following are met:

Diagnosis: The Member has a diagnosis of acne vulgaris

Prior therapies: The Member has had an inadequate response or intolerance to two or has contraindication to all of the following: a) Spironolactone; b) Topical antibiotic (e.g., clindamycin, erythromycin); c) Oral tetracycline (e.g., minocycline, doxycycline); d) Retinoic acid derivative (e.g., tretinoin, adapalene, isotretinoin); e) Benzoyl peroxide

Clindamycin Foam

Covered when ALL of the following are met:

Prior therapy: The Member has had an inadequate response to therapy with two preferred topical clindamycin formulations

Clindamycin/Benzoyl Peroxide combination

Covered when ALL of the following are met:

Prior therapy: The Member had an insufficient response to concurrent therapy with the individual topical ingredients, clindamycin and prescription-strength benzoyl peroxide.

Formulation: The request is for a generic (AB-rated) formulation

Erythromycin/Benzoyl Peroxide

Covered when ALL of the following are met:

Prior therapy: The Member has had an inadequate response to concurrent therapy with the individual topical ingredients, erythromycin and prescription-strength benzoyl peroxide

Formulation: The request is for a generic (AB-rated) formulation

Dapsone (Aczone 5% and 7.5% gel)

Covered when ALL of the following are met:

Prior therapy: The Member had an insufficient response to therapy with at least two alternative topical products: benzoyl peroxide, erythromycin, clindamycin, sulfacetamide or sulfacetamide/sulfur

Dapsone (Aczone) — Initial coverage criteria

Covered when ALL of the following are met for Dapsone (Aczone 5 and 7.5% gel):

Dapsone coverage criteria: Member had an insufficient response to therapy with at least two alternative topical products: benzoyl peroxide, erythromycin, clindamycin, sulfacetamide or sulfacetamide/sulfur.

Ivermectin (Soolantra) — Initial coverage criteria

Covered when ALL of the following are met for Ivermectin 1% cream (Soolantra):

Ivermectin coverage criteria: Member had an insufficient response to therapy with metronidazole and at least one additional generic topical agent used for the treatment of rosacea.

Noritate (metronidazole) — Initial coverage criteria

Covered when ALL of the following are met for Noritate (metronidazole) 1% cream:

Noritate coverage criteria: Member had an insufficient response to therapy with metronidazole 0.75% cream, gel or lotion AND Member had an insufficient response to therapy with generic metronidazole 1% gel.

Tazarotene — Coverage criteria

Covered when ONE of the following is met for Tazarotene:

Tazarotene coverage criteria: Member had an insufficient response to therapy with tretinoin OR the request is for an alternative dermatological inflammatory condition, such as plaque psoriasis.

Tretinoin — Coverage criteria

Covered when ALL of the following are met for Tretinoin (criteria apply to nonpreferred agents for all Members and preferred agents for M...):

Tretinoin coverage criteria: The request is for the treatment of acne, rosacea, cutaneous carcinoma, keratosis follicularis or verruca plana AND if the request is for a non-preferred formulation or a brand-name product: Member had an insufficient response to therapy with at least two preferred tretinoin formulations AND Member is 12 years of age or older.

Preferred formulations include generic tretinoin 0.025%, 0.05% and 0.1% cream, and generic tretinoin 0.01% and 0.025% gel.

This guideline does not apply to Medicare Members, including Members who are dual eligible for Medicare and the plan.

Unless otherwise noted, products packaged as medicated swabs or in pump dispensers are noncovered when bulk packaging is available. These products will not be approved for cosmetic purposes.

Requests for brand-name products that have AB-rated generics will be reviewed under the plan's Brand Name criteria; such brand requests may be denied if they do not meet the Brand Name requirements.

Provider Actions, Prior Authorization, and Documentation

Documentation Required

General coverage requirement

Coverage may be authorized only when ALL listed criteria for the requested product are met. Requests that do not document each required element (diagnosis, prior treatment history, and inadequate response or intolerance to stated alternatives) risk denial.

All required criteria must be documented in the medical record and submitted with the prior authorization request.
Requests lacking documentation of prior trials or inadequate response will be subject to denial.

Prior Authorization

Prior Authorization Required

Prior authorization is required for many acne and rosacea topical products (PA indicated for specific formulations in the product lists). Obtain prior authorization before dispensing any product marked PA.

Includes, but is not limited to: clindamycin-benzoyl peroxide combination gels (PA), Noritate 1% cream (PA), dapsone gels (PA), Soolantra (ivermectin 1% cream) (PA), Winlevi (clascoterone) (PA), Mirvaso (brimonidine) (PA).

Coding

CODESmixed

No codes listed

Background

This guideline lists FDA-approved topical and related products for acne and rosacea and specifies coverage determinations tied to the member’s documented diagnosis and prior treatment history, including required trials and documented inadequate response or intolerance to specified alternative topical or systemic agents.

Definitions and Product Notes

Panretin (alitretinoin) — Key facts

ProductPanretin (alitretinoin)

FDA‑approved indicationTopical treatment of cutaneous lesions in patients with AIDS-related Kaposi's sarcoma

LimitationNot indicated when systemic anti‑KS therapy is required (e.g., >10 new KS lesions in prior month, symptomatic lymphedema, symptomatic pulmonary KS, or symptomatic visceral involvement)

FormulationTopical

Mirvaso (brimonidine gel) — Key facts

ProductMirvaso (brimonidine gel)

FDA‑approved indication