CurrentUnitedHealthcarePolicy N/A

Isotretinoin Prior Authorization (Washington)

Prior authorization form and clinical criteria for non-preferred isotretinoin products for treatment of moderate to severe acne or rosacea for Washington Apple Health/UnitedHealthcare members; used by prescribers seeking PA for initiation or continuation of isotretinoin. Affects prescribers and pharmacy prior authorization reviewers.

Policy Summary

PayerUnitedHealthcare

PolicyIsotretinoin Prior Authorization (Washington)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of indication, enrollment in iPLEDGE, required prior trials (including at least two preferred isotretinoin trials for non-preferred requests), and required attachments (chart notes, labs, diagnostic results) with prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2preferred isotretinoin failures required for non-preferred products

1 mominimum adjunctive therapy trial duration

iPLEDGEREMS enrollment

Chart notesrequired documentation

Weight (kg)weight on form

Coverage Criteria for Isotretinoin Prior Authorization

Coverage criteria for isotretinoin prior authorization

Covered when ALL of the following are met:

Indication: Diagnosis of moderate to severe acne or moderate to severe rosacea (or other specified)

checkboxes on form

iPLEDGE: Prescriber and patient are enrolled in the iPLEDGE REMS program

checkbox on form

Prior trials for non-preferred isotretinoin: For non-preferred isotretinoin products, patient has tried and failed at least two preferred isotretinoin products OR documents intolerance to preferred products>=2 preferred product trials

form requests specification and durations

Policy Summary

PayerUnitedHealthcare

PolicyIsotretinoin Prior Authorization (Washington)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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The prior authorization form does not list discrete exclusions; instead it requires documentation of prior therapeutic trials and specific clinical information before coverage is considered. For acne, the form asks whether the patient has tried and failed listed therapies used in combination with topical benzoyl peroxide or a topical retinoid for at least 1 month (see checklist of oral antibiotics, benzoyl peroxide, topical retinoid, and female-specific options). For rosacea, the form similarly documents failures of listed topical therapies used in combination with oral antibiotics for at least 1 month. The form also captures prior full courses of isotretinoin and timing since completion when applicable.

Diagnosis and Coding Information

Diagnosis codesICD-10

ICD-10 CODE

Field for specific ICD-10 diagnosis code

Number of preferred isotretinoin trials required

Number of preferred isotretinoin trials required>= 2

Alternative to trialsPreferred isotretinoin product is not tolerated (document intolerance)

Where to specifyForm requests specification of the preferred isotretinoin products and duration

Adjunctive therapy trial duration

Adjunctive therapy trial duration>= 1 month

Acne combination requirementTherapies must be used in combination with topical benzoyl peroxide or a topical retinoid

Rosacea combination requirementTopical therapies must be used in combination with oral antibiotics

Examples listedOral antibiotics, benzoyl peroxide, topical retinoid, oral contraceptives, spironolactone (acne); topical ivermectin, topical antibiotics (rosacea)

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Isotretinoin Prior Authorization Required

Prior authorization is required for isotretinoin products. Use the UnitedHealthcare Prior Authorization Request Form and include the clinical information requested (indication, prior therapies tried, iPLEDGE enrollment, weight/date). Allow at least 24 hours for review. Fax completed form to 866-940-7328 or call 800-310-6826 with questions.

Complete entire Prior Authorization Request Form and submit to avoid delays
Indicate diagnosis (moderate to severe acne or rosacea) and whether request is continuation of therapy
Document iPLEDGE REMS enrollment for prescriber and patient
For non-preferred isotretinoin: document trial and failure of at least two preferred isotretinoin products or intolerance

Step Therapy

Step Therapy / Prior Trial Requirements

Step therapy / prior trial requirements must be documented. For acne, document failure of appropriate prior therapies used in combination with topical benzoyl peroxide or a topical retinoid for at least 1 month (e.g., oral antibiotics, benzoyl peroxide, topical retinoid; for females consider oral contraceptives or spironolactone). For rosacea, document failure of topical ivermectin or topical antibiotics used with oral antibiotics for at least 1 month. If requesting a non-preferred isotretinoin product, document trials of two (2) preferred isotretinoin products or a documented intolerance.

Acne: trial/failure of listed systemic or topical agents in combination with benzoyl peroxide or topical retinoid for >=1 month
Rosacea: trial/failure of topical ivermectin or topical antibiotics with oral antibiotics for >=1 month
Non-preferred product: tried and failed ≥2 preferred isotretinoin products or document intolerance

Documentation Required

Required Attachments & Signatures

Include all required attachments and a prescriber signature on the request. Missing documentation may result in denial or a delay in processing.

Attach chart notes documenting diagnosis, treatment history, and clinical response
Include relevant labs and diagnostic test results (e.g., baseline labs, pregnancy test results as applicable)
Provide prescriber signature, prescriber specialty, and date on the form

Denial Risk

Documentation Omissions — Risk of Denial

Failure to include the required attachments, prescriber signature, prescriber specialty, or date may result in denial of the request or delay in review. Ensure all requested fields on the form are completed and supporting documentation is legible.

Incomplete form or missing attachments = risk of denial or delayed decision
Verify prescriber signature, specialty, and date are present before submission
Ensure all prior-therapy fields (including product names and durations) are completed when applicable

OpenPayer

Isotretinoin Prior Authorization (Washington)

Coverage Criteria for Isotretinoin Prior Authorization

Diagnosis and Coding Information

Provider Actions, Prior Authorization & Documentation

Background and Indications

Definitions and Programs