CurrentNeighborhood Health Plan of Rhode IslandPolicy Adapalene PA with Limit Policy 351-C 08-2022

Topical Adapalene Prior Authorization and Quantity Limits

Defines prior authorization and quantity limit requirements for topical adapalene products (cream, gel, lotion, solution, swab) for treatment of acne vulgaris for members covered by Neighborhood Health Plan of Rhode Island via CVS Caremark.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical Adapalene Prior Authorization and Quantity Limits

Policy CodePolicy Adapalene PA with Limit Policy 351-C 08-2022

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization demonstrating a diagnosis of acne vulgaris and that requested quantities fall within product-specific limits or include body surface area documentation to justify additional quantity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipleformulations listed

21/63-dayquantity limits

Acne vulgarisindication required

Coverage Criteria

Initial prior authorization criteria

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Primary criteria: Patient has a diagnosis of acne vulgaris

Required for coverage

Quantity and supply: Requested quantity falls within the product-specific quantity limits OR documentation provided that body surface area requires additional quantitiesSee product-specific quantity limits (e.g., Differin cream 0.1%: 45 g/21 days lower limit; 90 g/21 days upper limit; Adapalene topical solution: 120 mL/21 days lower limit; 240 mL/21 days upper limit).

Quantity limits detailed in policy; if additional quantities are requested, documentation must show the body surface area being treated to justify quantities beyond the standard limit.

No explicit clinical exclusions are listed in this policy beyond the indication requirement and the product-specific quantity limits. Coverage is governed by the documented diagnosis of acne vulgaris and adherence to the specified supply limits for each formulation; additional supplies may be considered only with supporting documentation (see quantity limits).

Providers should follow the product-specific limits (for example, gram/mL/swab limits per 21- and 63-day windows) when prescribing adapalene formulations to avoid denials or reduced approvals.

Use is not authorized when the patient does not have a documented diagnosis of acne vulgaris. Requests will also be considered not authorized if the quantity requested exceeds the policy’s specified limits and the prescription does not include justification for additional amounts.

If greater-than-standard quantities are needed, the submission must include documentation (for example, body surface area treated) to justify quantities beyond the listed limits; otherwise the request may be denied or limited.

Coding and Quantity Limits

Covered topical adapalene productsmixedCovered

Differin Cream 0.1%	adapalene cream 0.1%
Adapalene Gel 0.1%	adapalene gel 0.1%
Adapalene Topical Solution 0.1% (swab)	adapalene topical solution 0.1% swab
Differin Gel 0.3%	adapalene gel 0.3%
Differin Lotion 0.1%	adapalene lotion 0.1%

Quantity limits (examples)

Adapalene topical solution (liquid)Lower limit = 120 mL / 21 days; 12‑week lower limit = 360 mL / 63 days; Upper limit = 240 mL / 21 days; 12‑week upper limit = 720 mL / 63 days

Adapalene topical solution (swab)Lower limit = 28 swabs / 21 days; 12‑week lower limit = 84 swabs / 63 days; Upper limit = 56 swabs / 21 days; 12‑week upper limit = 168 swabs / 63 days

Differin cream 0.1% (adapalene cream)Lower limit = 45 grams / 21 days; 12‑week lower limit = 135 grams / 63 days; Upper limit = 90 grams / 21 days; 12‑week upper limit = 270 grams / 63 days

Adapalene gel 0.1%Lower limit = 45 grams / 21 days; 12‑week lower limit = 135 grams / 63 days; Upper limit = 90 grams / 21 days; 12‑week upper limit = 270 grams / 63 days

Differin lotion 0.1% (adapalene lotion)Examples: 45 grams / 21 days = 59 mL / 21 days; 135 grams / 63 days = 177 mL / 63 days; 90 grams / 21 days = 118 mL / 21 days; 270 grams / 63 days = 354 mL / 63 days

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for adapalene. The request will be approved only when the patient has a documented diagnosis of acne vulgaris.

Prior authorization required

Denial Risk

Indication Requirement

Document the indication clearly on the PA submission. Requests may be denied if there is no diagnosis of acne vulgaris documented in the medical record or on the prior authorization request.

Indication must be acne vulgaris

Denial Risk

Quantity Limit Excess

Quantity limits apply. If the requested quantity exceeds the standard limits, provide clinical justification and supporting documentation. Requests that exceed quantity limits without adequate justification may be denied or approved at a reduced quantity.

Quantity limits defined (see policy)
Excess quantities risk denial or limitation

Documentation Required

Body Surface Area Justification

If requesting quantities beyond the standard limits, document the patient’s affected body surface area (BSA) and explain why additional quantity is medically necessary to treat the documented BSA.

Record BSA when requesting increased quantity
Provide rationale linking BSA to required quantity

Background

Topical adapalene formulations are indicated for the treatment of acne vulgaris. The policy lists multiple covered formulations (cream, gel, lotion, solution, swab) and ties coverage to the presence of the acne vulgaris diagnosis.

Differin Gel 0.3% and Differin Lotion 0.1% are noted in the policy context as topical adapalene products intended for acne; approval under this policy requires documentation of the clinical diagnosis and conformity with the product-specific quantity limits.

Definitions

Acne vulgaris — coverage definition

DefinitionAcne vulgaris: a documented clinical diagnosis required for coverage of topical adapalene products.

Product indicationsDifferin Cream 0.1%, Adapalene Gel 0.1%, Adapalene Topical Solution 0.1% (swab), and Adapalene Topical Solution 0.1% are indicated for the topical treatment of acne vulgaris.

Age-specific indicationDifferin Gel 0.3% and Differin Lotion 0.1% are indicated for the topical treatment of acne vulgaris in patients 12 years of age and older.