CurrentNeighborhood Health Plan of Rhode IslandPolicy 351-C

Adapalene topical prior authorization and quantity limits

Defines prior authorization and quantity limit rules for topical adapalene products (gels, creams, lotions, solutions, swabs) for treatment of acne vulgaris for members of Neighborhood Health Plan of Rhode Island under CVS Caremark management.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdapalene topical prior authorization and quantity limits

Policy CodePolicy 351-C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrior authorization is required for initial and continuation use of topical adapalene products; for continuation the provider must document a positive clinical response (e.g., reduction in lesion count).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 monthsInitial approval

12 monthsContinuation approval

45–270 gGel/cream limits

28–168 swabsSolution/swab limits

Coverage and Authorization Criteria

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Coverage criteria

Covered when ALL of the following are met:

Indication and use: The requested drug is being prescribed for the topical treatment of acne vulgaris

FDA-approved indication required

Initial vs continuation: The request is NOT for continuation of therapy OR the request is for continuation of therapy

Policy lists both initial and continuation pathways

Continuation requirement: For continuation requests, the patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions)

Documented clinical improvement required for continuation

Quantity limit criteria

Quantity limits apply as specified below (values listed as lower/upper limits per 4- and 12-week periods):

Adapalene topical solution (mL): Lower limit 4-week = 120 mL / 21 days; 12-week = 360 mL / 63 days. Upper limit 4-week = 240 mL / 21 days; 12-week = 720 mL / 63 days.

Applies to topical solution formulations

Adapalene topical solution (swab): Lower limit 4-week = 28 swabs / 21 days; 12-week = 84 swabs / 63 days. Upper limit 4-week = 56 swabs / 21 days; 12-week = 168 swabs / 63 days.

Applies to swab presentations

Differin cream/gel 0.1% and Differin gel 0.3%: Lower limit 4-week = 45 grams / 21 days; 12-week = 135 grams / 63 days. Upper limit 4-week = 90 grams / 21 days; 12-week = 270 grams / 63 days.

Applies to cream and gel formulations; gel 0.3% included

Differin lotion 0.1%: Lower limit 4-week = 59 mL / 21 days; 12-week = 177 mL / 63 days. Upper limit 4-week = 118 mL / 21 days; 12-week = 354 mL / 63 days.

Applies to lotion formulation

This policy applies only to topical adapalene products used for the treatment of acne vulgaris. Coverage is granted with prior authorization when the medication is being prescribed for that FDA‑approved indication and the request meets the policy’s coverage criteria. Prior authorization is required for both initial and continuation use of topical adapalene formulations.

Requests that are not for the topical treatment of acne vulgaris are not supported by this policy. For continuation requests the provider must document that the patient has achieved or maintained a positive clinical response (for example, reduction in lesion count) to justify ongoing therapy; requests failing to demonstrate clinical response or lacking required documentation risk denial.

Provider Responsibilities and Authorization Workflow

Prior Authorization

Prior Authorization Required

Prior authorization is required for both initial and continuation use. Requests must be for topical treatment of acne vulgaris.

Affects topical retinoid (adapalene) prior authorization requests
Initial and continuation requests require prior auth

Step Therapy

Step therapy

No explicit step-therapy (fail‑first) requirements are stated in the coverage criteria; there are no mandated prior trials of alternative agents documented.

Documentation Required

Clinical response documentation

Continuation (renewal) requests must include documentation of a positive clinical response (e.g., reduction in number of lesions or other clinical improvement).

Document improvement such as reduced lesion count or maintained clinical benefit

Denial Risk

Denial triggers

Requests will be denied if the request is not for topical treatment of acne vulgaris, if prior authorization is not obtained, or if continuation requests lack documentation of positive clinical response.

Non‑topical use is not covered
Missing prior authorization will trigger denial
Continuation without documented improvement will be denied

Key Definitions

Acne vulgaris indication — Differin/adapalene formulations

IndicationDifferin (adapalene) formulations are indicated for the topical treatment of acne vulgaris.

Formulations coveredCream 0.1%, Gel 0.1%, Gel 0.3%, Lotion 0.1%, Topical solution (including swab presentations).

Age-specific noteDifferin Gel 0.3% and Differin Lotion 0.1% are indicated for patients 12 years of age and older.

Swab/solution wordingAdapalene topical solution (including swab presentation) is FDA‑approved for topical treatment of acne vulgaris.

Clinical scopePolicy limits coverage to topical treatment of acne vulgaris per product labeling — other indications are not supported.

OpenPayer

Adapalene topical prior authorization and quantity limits

Coverage and Authorization Criteria

Provider Responsibilities and Authorization Workflow

Key Definitions

Background and Clinical Context