CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Topical adapalene (Differin) prior authorization

Defines prior authorization and quantity limit requirements for topical adapalene products (cream, gel, lotion, solution, swab) used to treat acne vulgaris for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical adapalene (Differin) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document a diagnosis of acne vulgaris; justify any request for additional quantities with treated body surface area.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleproduct forms covered

21-/63-dayquantity limit windows

acne vulgariscovered indication

Coverage Criteria

Initial prior authorization — Covered when ALL of the following are met

Covered when ALL of the following are met

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There are no explicit clinical exclusions listed in this policy for topical adapalene products. The policy does, however, include quantity limits by formulation and notes that pharmacies may dispense per manufacturer package size at their discretion up to those limits. Providers should be aware that requests for quantities exceeding the stated limits will require additional justification (see documentation and prior authorization requirements).

This policy defines prior authorization requirements specifically for the treatment of acne vulgaris. Coverage with prior authorization is limited to that diagnosis; uses of topical adapalene for indications other than acne vulgaris are not supported by this document. When additional quantities are requested, the prescriber must document that the treated body surface area requires the larger quantity.

Products, Codes, and Quantity Limits

Products and quantity limit descriptorsmixed

N/A

No explicit CPT/HCPCS/ICD-10/NDC codes listed in document; product and quantity limits specified by formulation and grams/mL/swabs. Specific quantity limits: Adapalene topical solution — 120 mL per 21 days (lower), 360 mL per 63 days (lower 12-week), 240 mL per 21 days (upper), 720 mL per 63 days (upper 12-week); Adapalene topical solution (swab) — 28 swabs per 21 days (lower), 84 swabs per 63 days (lower 12-week), 56 swabs per 21 days (upper), 168 swabs per 63 days (upper 12-week); Differin cream 0.1% (adapalene cream) — 45 g per 21 days (lower), 135 g per 63 days (lower 12-week), 90 g per 21 days (upper), 270 g per 63 days (upper 12-week); Adapalene gel 0.1% — 45 g per 21 days (lower), 135 g per 63 days (lower 12-week), 90 g per 21 days (upper), 270 g per 63 days (upper 12-week).

Quantity limits by formulation — examples (21-day and 63-day windows)

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

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

Differin cream 0.1% (adapalene cream)Lower limit: 45 grams per 21 days; Lower 12-week limit: 135 grams per 63 days; Upper limit: 90 grams per 21 days; Upper 12-week limit: 270 grams per 63 days.

Adapalene gel 0.1%Lower limit: 45 grams per 21 days; Lower 12-week limit: 135 grams per 63 days; Upper limit: 90 grams per 21 days; Upper 12-week limit: 270 grams per 63 days.

Differin lotion 0.1% (adapalene lotion)Examples provided in grams/mL equivalence: 45 g = ~59 mL per 21 days; 135 g = ~177 mL per 63 days; 90 g = ~118 mL per 21 days; 270 g = ~354 mL per 63 days.

Provider Actions and Requirements

Prior Authorization

Prior authorization required; approval conditions

Prior authorization is required. Approval is granted when the patient has a diagnosis of acne vulgaris. If additional quantities are requested, the prescriber must document that the treated body surface area requires the additional quantities; quantity limits apply.

Step Therapy

No step therapy specified

No step therapy requirements are specified in this policy.

Documentation Required

Documentation and dispensing expectations

Pharmacy may dispense quantities per manufacturer package size up to the stated quantity limits; when requesting quantities above the limits, the prescriber must document the body surface area treated to justify the larger quantity.

Dispensing pharmacy may fill quantities per package size up to the quantity limits.
Documentation of treated body surface area is required to justify additional quantities beyond the stated limits.

Denial Risk

Denial triggers for missing diagnosis or insufficient quantity justification

Requests may be denied if the patient does not have a diagnosis of acne vulgaris or if additional quantities are requested without documentation that the treated body surface area requires more than the quantity limits.

No acne vulgaris diagnosis documented.
Insufficient justification (no treated body surface area documentation) for quantities above policy limits.

Background

Topical adapalene is available in multiple formulations and strengths (cream, gel, lotion, solution, and swab formats, commonly 0.1% and 0.3%). These products are indicated for the topical treatment of acne vulgaris, with certain formulations (for example, Differin Gel 0.3% and Differin Lotion 0.1%) indicated for patients aged 12 years and older. The policy sets formulation-specific quantity limits to align with typical fill periods and package sizes (examples include 120 mL per 21 days or 360 mL per 63 days for solution; 45 g per 21 days up to 270 g per 63 days for cream/gel; and 28 swabs per 21 days up to 168 swabs per 63 days).

Definitions

Acne vulgaris indication — product strengths and indicated uses

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

Differin Gel 0.3%Differin Gel 0.3% is indicated for the topical treatment of acne vulgaris in patients 12 years of age and older.

Differin Lotion 0.1%Differin Lotion 0.1% is indicated for the topical treatment of acne vulgaris in patients 12 years of age and older.