CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior Authorization Criteria — Topical tretinoin and combination topical retinoids

Prior authorization criteria for topical tretinoin products and combination topical retinoids for treatment of acne vulgaris and selected compendial use (keratosis follicularis) for members of Neighborhood Health Plan of Rhode Island (CVS Caremark criteria document).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical tretinoin and combination topical retinoids prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document a diagnosis of acne vulgaris or keratosis follicularis; for continuation, document a positive clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≈10products named

4 moInitial DOA

12–36 moContinuation DOA

AcnePrimary indication

Coverage and Medical Necessity Criteria

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Coverage and Continuation Criteria

Covered when the following criteria are met:

Primary coverage: The patient has a diagnosis of acne vulgaris

From coverage criteria header

Alternate covered indication: The patient has a diagnosis of keratosis follicularis (Darier's disease, Darier-White disease)

Compendial use listed in policy

Continuation vs. initial request logic: Request is NOT for continuation of therapy OR request is for continuation of therapy with documented positive clinical response (e.g., reduction in number of lesions)

Continuation requires evidence of maintained or achieved clinical benefit

Requests for topical tretinoin or combination topical retinoid products that do not include a documented diagnosis of acne vulgaris or keratosis follicularis (Darier's disease) are not supported by the coverage criteria in this policy. Prior authorization decisions require one of these diagnoses to be present in the clinical record.

The policy text does not list additional explicit not medically necessary conditions beyond the absence of the covered diagnoses. In other words, apart from requiring a diagnosis of acne vulgaris or keratosis follicularis, the document does not specify other NMN exclusions.

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage. Approvals are granted per the durations below and differ by product code for initial versus continuation therapy.

237-A: Initial therapy DOA: 4 months; Continuation of therapy DOA: 12 months
355-A: Initial therapy DOA: 4 months; Continuation of therapy DOA: 36 months

Step Therapy

No Step Therapy / Trial Requirements

Step therapy or required topical/previous trials: None required. There is no explicit step therapy or mandated trial sequence for initial approval.

Documentation Required

Documentation Required for Initial and Continuation Requests

Required documentation must demonstrate the clinical indication and treatment response. For initial requests, submit documentation showing diagnosis (e.g., acne vulgaris or keratosis follicularis/Darier's disease) and rationale for the requested agent. For continuation requests, provide evidence of positive clinical response or maintenance of benefit (for example, reduction in lesion count or other clinical improvement). Include relevant medical records, prior therapy history, and treatment dates.

Diagnosis documentation: acne vulgaris OR keratosis follicularis (Darier's disease)
For initial requests: clinical rationale and prior treatment history
For continuation requests: objective evidence of improvement or maintained benefit (e.g., decreased lesion count)
Attach relevant medical records and treatment dates

Denial Risk

Denial Triggers

Requests lacking required diagnosis or supporting clinical documentation will be denied. Other denial triggers include absence of evidence of benefit for continuation requests and missing treatment history when relevant.

Missing or unclear diagnosis (must indicate acne vulgaris or keratosis follicularis)
No documentation of clinical response for continuation requests
Failure to provide prior treatment history or supporting medical records

Initial Therapy Coverage Criteria and Duration

Initial Therapy

Initial therapy — covered when all of the following are met:

Initial approval criteria: Patient has a diagnosis of acne vulgaris (or keratosis follicularis where applicable); the request is NOT for continuation of therapy

Initial Duration of Approval (DOA): 4 months

Continuation Therapy Criteria and Duration

Continuation Therapy

Continuation therapy — requirements to approve continuation requests:

Continuation approval: Request is for continuation of therapy AND patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions)

Continuation DOA: 12 months for policy 237-A; 36 months for policy 355-A

Definitions and Compendial Uses

inv-09: Keratosis follicularis (Darier's disease) — compendial use entry

TermKeratosis follicularis (Darier's disease)

Alternate name(s)Darier-White disease

Policy relevanceListed as a compendial use for topical tretinoins and included as an alternate covered diagnosis under the coverage criteria

Coverage implicationRequests with this diagnosis may be approved with prior authorization when continuation criteria and documentation requirements are met

Supporting sourceCompendial uses section and coverage criteria in policy (see compendial listing and coverage criteria for acne/keratosis follicularis)

Clinical Background

Topical tretinoins and combination tretinoin products are included in this policy as agents used primarily for the treatment of acne vulgaris (coverage is by prior authorization when criteria are met). Some formulations and combination products are referenced by the policy as subject to the same coverage requirements; compendial use for keratosis follicularis (Darier's disease) is also noted as a covered indication when supported by documentation.