CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Topical tretinoin coverage for acne vulgaris

Policy governs prior authorization, age limits, quantity limits, and approval criteria for topical tretinoin for members covered under Medicaid at Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical tretinoin coverage for acne vulgaris

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; approvals may be granted for up to 12 months if age and diagnosis criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤40age restriction (years)

12 moauthorization period

20 g/30dcream max qty

15 g/30dgel max qty

Medicaidpayer scope

Coverage criteria for topical tretinoin

Approval criteria

Covered when ALL of the following are met

Age requirement: Patient is age 40 years or younger (maximum age of 40)<= 40 years

policy states maximum age of 40

Diagnosis requirement: Patient has a diagnosis of acne vulgarisdiagnosis present

required for authorization; authorization of 12 months may be granted when criteria are met

Use of topical tretinoin is not authorized for members older than 40 years. The policy specifies a maximum age of 40, and requests for patients exceeding this age limit may be denied.

Quantity limits apply by formulation and strength. Requests that exceed these limits are not covered under the policy: tretinoin creams (0.1%, 0.05%, 0.025%) — 20 g per 30 days, and tretinoin gels (0.01%, 0.025%) — 15 g per 30 days. Authorization should not be granted for quantities beyond these stated limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical tretinoin coverage for acne vulgaris

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; approvals may be granted for up to 12 months if age and diagnosis criteria are met.

SourceLink

On This Page

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Quantity limits and coding

Quantity limits by formulation and strengthmixedCovered

Tretinoin cream 0.1%	20 grams per 30 days
Tretinoin cream 0.05%	20 grams per 30 days
Tretinoin cream 0.025%	20 grams per 30 days
Tretinoin gel 0.01%	15 grams per 30 days
Tretinoin gel 0.025%	15 grams per 30 days

inv-05: Maximum age

Maximum age (years)40

Applies toTopical tretinoin prior authorization and coverage

Authorization period when approvedUp to 12 months (per prior authorization criteria)

ScopeMedicaid

Provider requirements and prior authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for topical tretinoin when criteria are met. When approved, prior authorization may be granted for up to 12 months.

Authorization duration: up to 12 months

Note

Provider Action

(Provider action placeholder) Additional operational or provider-facing notes may be placed here as needed.

Documentation Required

Required Clinical Documentation

Documentation submitted to support an authorization request must include clinical evidence of a diagnosis of acne vulgaris.

Required documentation: clinical diagnosis of acne vulgaris
Scope note: policy applies to Medicaid members

Denial Risk

Denial Triggers

Requests for members over the maximum age of 40 or requests lacking documentation of an acne vulgaris diagnosis are at high risk for denial.

Denial triggers: member age > 40
Denial triggers: absence of documented diagnosis of acne vulgaris

Background

Topical tretinoin is used for management of acne vulgaris and is addressed here within the Medicaid scope. This policy defines approval criteria that include both an age restriction and quantity limits by formulation and strength. Specifically, the policy sets a maximum age of 40 for covered use and establishes per‑30‑day quantity limits of 20 g for tretinoin creams (0.1%, 0.05%, 0.025%) and 15 g for tretinoin gels (0.01%, 0.025%). Prior authorization may be granted when the member meets these requirements and has a documented diagnosis of acne vulgaris.

Key definitions

inv-11: Diagnosis required to support authorization

Required diagnosisAcne vulgaris

Use for authorizationDocumentation of acne vulgaris must be provided to support prior authorization

ContextAuthorization of 12 months may be granted for topical tretinoin when acne vulgaris diagnosis is present