Tretinoin prior authorization criteria (Kentucky Medicaid)
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Defines new prior authorization clinical criteria for tretinoin formulations for Kentucky Medicaid (Fee-for-Service and MCO) effective June 1, 2026; affects pharmacy providers, prescribers, and beneficiaries covered by Kentucky Medicaid.
Tretinoin cream, tretinoin microsphere gel, and clindamycin/tretinoin gel are subject to prior authorization beginning 06/01/2026.
Approval duration set to 1 year when criteria met.
Clinical criteria require diagnosis of acne vulgaris and prescriber attestation that the medication is not being used solely for cosmetic purposes.
Coverage Criteria
Initial authorization
Covered when ALL of the following are met:
Approval duration: 1 year when criteria are met.
Use solely for cosmetic purposes is excluded from coverage under these criteria. Examples of cosmetic indications that are not covered include photoaging, wrinkling, hyperpigmentation, melasma, roughness of skin, or sun damage.
As part of the approval requirements, the prescriber must attest that the tretinoin product is not being used solely for cosmetic purposes. Requests where the prescriber attests the medication is being used solely for cosmetic indications will not meet medical necessity and therefore will not satisfy the criteria for prior authorization.
Affected Products & Coding
| tretinoin cream | tretinoin cream |
| tretinoin microsphere gel (gel pump) | tretinoin microsphere gel (gel pump) |
| clindamycin/tretinoin gel | clindamycin/tretinoin gel |
| not specified | No specific NDC, HCPCS, or CPT codes were listed in the document; agents were identified by name/description. |
Provider Actions & Prior Authorization
Prior authorization required for specified tretinoin products
Prior authorization is required for tretinoin cream, tretinoin microsphere gel (gel pump), and clindamycin/tretinoin gel for Kentucky Medicaid effective 06/01/2026; approvals are granted for 1 year when criteria are met. Pharmacy providers should work with prescribers and patients to obtain PA or consider alternatives as appropriate.
- Effective date: 06/01/2026
- Agents: tretinoin cream; tretinoin microsphere gel (gel pump); clindamycin/tretinoin gel
- Approval duration when criteria met: 1 year
Provider resources and contacts
Pharmacy providers are encouraged to reference the Kentucky Medicaid PDL and Prior Authorization documents on the MedImpact Provider Portal and to contact the Kentucky MedImpact team for Fee-for-Service or MCO questions.
- Provider portal: https://kyportal.medimpact.com/provider-documents/drug-information
- Fee-for-Service contact: KYMFFS@medimpact.com
- MCO contact: KYMCOPBM@medimpact.com
Required prescriber attestation regarding non-cosmetic use
The prescriber must attest that the tretinoin product is not being used solely for cosmetic purposes; examples of cosmetic uses are listed in the policy and must be considered when attesting.
- Examples of cosmetic purposes: photoaging, wrinkling, hyperpigmentation, melasma, roughness of skin, or sun damage
Criteria-based denials for missing diagnosis or attestation
Requests will be denied if the approval criteria are not met — specifically when there is no diagnosis of acne vulgaris or when the prescriber attestation that the medication is not being used solely for cosmetic purposes is missing.
- Denial triggers: absence of an acne vulgaris diagnosis; missing prescriber attestation of non-cosmetic use
Definitions
Initial Therapy Criteria
Initial therapy
Initial authorization
Approval duration: 1 year when criteria are met.
Continuation / Renewal Criteria
Renewal criteria
Continuation/renewal
Background
Tretinoin products are topical retinoids commonly used to treat acne vulgaris. This policy implements prior authorization for specified tretinoin formulations for Kentucky Medicaid effective 06/01/2026. The agents subject to the criteria are tretinoin cream, tretinoin microsphere gel (gel pump), and clindamycin/tretinoin gel. When the clinical criteria are met — a diagnosis of acne vulgaris and prescriber attestation that the product is not being used solely for cosmetic purposes — approvals are granted for 1 year.
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