CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Quantity Limit and Prior Authorization Criteria — Combination Topical Acne Products

This policy defines quantity limits and post-limit prior authorization criteria for combination topical acne products (clindamycin/benzoyl peroxide, erythromycin/benzoyl peroxide, and clindamycin/adapalene/benzoyl peroxide) and applies to prescription fills under the payer's pharmacy benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyQuantity Limit and Prior Authorization Criteria — Combination Topical Acne Products

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf a requested quantity exceeds the initial limit the claim will reject and prior authorization is required; the drug will be covered with prior authorization when specified clinical criteria are met for topical treatment of acne vulgaris.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

25 daysdefault month duration

75 daysdefault 3-month duration

4 monthsinitial approval DOA

12 monthscontinuation approval DOA

up to 100 g

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Coverage Criteria and Quantity Limits

Post-limit prior authorization coverage criteria

Covered with prior authorization when the following nested criteria are met:

Requested drug is being prescribed for the topical treatment of acne vulgaris

Quantity limits apply (see Quantity limits criteria)

Continuation or new request

The request is NOT for continuation of therapy
ALL of the following
- The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions)

If the requested quantity exceeds the initial quantity limit, prior authorization must be obtained for coverage

Dispensing discretion: pharmacy may fill per manufacturer package sizes up to stated quantity limits

Pharmacy may dispense per manufacturer package sizes up to these quantity limits; day supply may be less than indicated due to packaging.

Quantity limits

Specified quantity limits for initial fills and post-PA (post-limit) fills by product and period.

Acanya (clindamycin phosphate–benzoyl peroxide gel): Initial month limit = 50 g (25 days); Initial 3-month limit = 150 g (75 days); Post-PA month limit = 100 g (25 days); Post-PA 3-month limit = 300 g (75 days)

BenzaClin (clindamycin phosphate–benzoyl peroxide gel): Initial month limit = 50 g (25 days); Initial 3-month limit = 150 g (75 days); Post-PA month limit = 100 g (25 days); Post-PA 3-month limit = 300 g (75 days)

Benzamycin (erythromycin–benzoyl peroxide gel): Initial month limit = 47 g (25 days); Initial 3-month limit = 141 g (75 days); Post-PA month limit = 94 g (25 days); Post-PA 3-month limit = 282 g (75 days)

Cabtreo (clindamycin phosphate–adapalene–benzoyl peroxide gel): Initial month limit = 50 g (25 days); Initial 3-month limit = 150 g (75 days); Post-PA month limit = 100 g (25 days); Post-PA 3-month limit = 300 g (75 days)

Neuac (clindamycin phosphate–benzoyl peroxide 1.2%–5% gel): Initial month limit = 45 g (25 days); Initial 3-month limit = 135 g (75 days); Post-PA month limit = 90 g (25 days); Post-PA 3-month limit = 270 g (75 days)

Approval durations

Duration of approvals for prior authorization decisions.

Initial therapy duration of approval (DOA): 4 months

Continuation of therapy DOA: 12 months

Products and Quantity Metrics

Listed combination topical acne productsmixedCovered

ACANYA	clindamycin phosphate-benzoyl peroxide gel
BENZACLIN	clindamycin phosphate-benzoyl peroxide gel
BENZAMYCIN	erythromycin/benzoyl peroxide gel
CABTREO	clindamycin phosphate-adapalene-benzoyl peroxide gel
ONEXTON	clindamycin phosphate-benzoyl peroxide gel
Neuac	clindamycin phosphate-benzoyl peroxide gel (generic Duac)

Month and 3-month gram limits — initial and post‑PA

Initial month gram limits (examples)Acanya/BenzaClin/Cabtreo/Onexton: 50 g per month (25-day period); Benzamycin: 47 g per month (25-day period); Neuac: 45 g per month (25-day period)

Initial 3-month gram limits (examples)Acanya/BenzaClin/Cabtreo/Onexton: 150 g per 3 months (75-day period); Benzamycin: 141 g per 3 months (75-day period); Neuac: 135 g per 3 months (75-day period)

Post‑limit (post‑PA) month gram limits (examples)Acanya/BenzaClin/Cabtreo/Onexton: 100 g per month (25-day period); Benzamycin: 94 g per month (25-day period); Neuac: 90 g per month (25-day period)

Post‑limit (post‑PA) 3‑month gram limits (examples)Acanya/BenzaClin/Cabtreo/Onexton: 300 g per 3 months (75-day period); Benzamycin: 282 g per 3 months (75-day period); Neuac: 270 g per 3 months (75-day period)

Provider Actions and Pharmacy Dispensing

Prior Authorization

Prior Authorization Required for Quantities Over Initial Limit

If the patient requests more than the initial quantity limit, the claim will reject with a message indicating a prior authorization is required. Requests for quantities beyond the initial limits will be evaluated against the prior authorization clinical criteria; coverage is contingent on meeting those criteria and an approved PA must be in place before the over-limit quantity will be paid.

Reject message: prior authorization required for quantities over initial limit
Coverage contingent on meeting PA clinical criteria and approved PA prior to payment

Note

Pharmacy Dispensing Discretion Regarding Package Sizes

Manufacturer package sizes may vary. It is at the dispensing pharmacy's discretion to fill per manufacturer package sizes up to the stated quantity limits. When package-size dispensing is used, the filled quantity and the day supply reported on the claim may differ from the nominal per-fill amount (e.g., a 25-day equivalent used for a 30-day fill or 75-day equivalent for a 90-day fill to allow refill processing).

Pharmacy may dispense manufacturer package sizes up to the listed quantity limits

Definitions and Quantity Limit Notes

Prior authorization — when required and coverage conditions

When prior authorization is requiredPrior authorization is required when a request exceeds the initial quantity limit; the requested drug will be covered with prior authorization when the coverage criteria are met (e.g., prescribed for topical treatment of acne vulgaris).

Coverage contingent on clinical criteriaCoverage with prior authorization is allowed when the medication is prescribed for the topical treatment of acne vulgaris and applicable continuation or clinical response conditions are met.

Claim processing behaviorIf the requested quantity exceeds the initial limit the claim will reject and prior authorization must be obtained for the higher (post‑limit) quantity.

Quantity limit — maximum allowed grams and packaging/day‑supply note

Definition — quantity limitA quantity limit is the maximum allowed grams per month or per 3‑month period for each product (examples provided per product below).