CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Adapalene Pa With Limit Policy 351 C Udr 08 2023

Prior authorization policy (initial and continuation) with specific quantity limits and durations of approval for adapalene topical products (gels, creams, lotions, solutions, swabs) for topical treatment of acne vulgaris. Specifies required clinical response for continuation and enumerates per-product 4-week and 12-week quantity limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdapalene Pa With Limit Policy 351 C Udr 08 2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for adapalene topical products; approval provided only when prescribed for acne vulgaris and meets initial/continuation criteria and quantity limits.

SourceLink

POLICY UPDATE CHANGES

No material changes

6Formulations with explicit limits listed

4m / 12mInitial / Continuation DOA

Coverage Summary & Prior Authorization

Prior authorization is required for adapalene topical products for the topical treatment of acne vulgaris. Coverage is available with prior authorization when the request meets the policy’s initial or continuation criteria and adheres to the per-product quantity limits and durations of approval. Formulations covered include gels, creams, lotions, solutions, and swabs.

Coverage / Prior Authorization Criteria

The requested drug will be covered with prior authorization when the following criteria are met:

ALL of the following

Top-level coverage criteria: The requested drug is being prescribed for the topical treatment of acne vulgaris
Initial OR Continuation
- Initial Therapy: The request is NOT for continuation of therapy
- Continuation Therapy: The request is for continuation of therapy
Continuation response requirement: For continuation of therapy: The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions, etc.)
Quantity limits reference: Requested quantities must be within the defined quantity limits for the specific adapalene formulation (see Quantity Limits node)
Pharmacy may fill per manufacturer package size up to these limits (see Quantity Limits).

Continuation Therapy Criteria

Documentation Required

Documentation of clinical response for continuation

For continuation requests, document that the patient has achieved or maintained a positive clinical response. Examples of objective documentation include demonstrated improvement such as a reduction in the number of lesions or other clinical notes showing treatment benefit.

Lesion counts (before and after)
Progress/clinical notes documenting improvement

Quantity Limits (per product and fill period)

Quantity limits are applied per product/formulation and per fill period (4-week = 21 days for 28-day fill; 12-week = 63 days for 84-day fill). Pharmacy may fill per manufacturer package size up to these limits.

Adapalene topical solution (standard): 4-week lower = 120 mL / 21 days; 12-week lower = 360 mL / 63 days; 4-week upper = 240 mL / 21 days; 12-week upper = 720 mL / 63 days

Adapalene topical solution (swab): 4-week lower = 28 swabs / 21 days; 12-week lower = 84 swabs / 63 days; 4-week upper = 56 swabs / 21 days; 12-week upper = 168 swabs / 63 days

Differin cream 0.1% (adapalene cream): 4-week lower = 45 grams / 21 days; 12-week lower = 135 grams / 63 days; 4-week upper = 90 grams / 21 days; 12-week upper = 270 grams / 63 days

Adapalene gel 0.1%: 4-week lower = 45 grams / 21 days; 12-week lower = 135 grams / 63 days; 4-week upper = 90 grams / 21 days; 12-week upper = 270 grams / 63 days

Differin gel 0.3% (adapalene gel): 4-week lower = 45 grams / 21 days; 12-week lower = 135 grams / 63 days; 4-week upper = 90 grams / 21 days; 12-week upper = 270 grams / 63 days

Differin lotion 0.1% (adapalene lotion): 4-week lower = 59 mL / 21 days; 12-week lower = 177 mL / 63 days; 4-week upper = 118 mL / 21 days; 12-week upper = 354 mL / 63 days

Billing Rule

Pharmacy dispensing per package size up to quantity limits

The dispensing pharmacy may fill quantities based on manufacturer package sizes up to the stated quantity limits. Because package sizes vary, the filled quantity and the day supply recorded may be less than the requested amount.

Policy thresholds summary

Threshold summarySee per-product 4-week and 12-week limits (e.g., solution 4-week lower=120 mL / upper=240 mL; solution swab 4-week lower=28 swabs / upper=56 swabs; cream/gel 0.1% 4-week lower=45 g / upper=90 g; lotion 0.1% 4-week lower=59 mL / upper=118 mL)

Formulations with explicit limits listed6

Quantity limit example — Differin cream 0.1% (4-week)Lower = 45 grams; Upper = 90 grams

Quantity limit example — Adapalene topical solution (4-week)Lower = 120 mL; Upper = 240 mL

Quantity limit example — Adapalene topical solution (swab) (4-week)Lower = 28 swabs; Upper = 56 swabs

Initial / Continuation DOA4 months / 12 months

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdapalene Pa With Limit Policy 351 C Udr 08 2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for adapalene topical products; approval provided only when prescribed for acne vulgaris and meets initial/continuation criteria and quantity limits.

SourceLink

On This Page

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Adapalene Pa With Limit Policy 351 C Udr 08 2023

Coverage Summary & Prior Authorization

Initial Therapy Criteria

Continuation Therapy Criteria

Quantity Limits (per product and fill period)

Applicable Codes

Background

Revision History