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Retin-a micro — Blue Cross Blue Shield of Montana

acne or other FDA-approved indication for topical retinoids

Preferred products

  • adapalene
  • tazarotene
  • tretinoin
  • adapalene-benzoyl peroxide

Initial criteria

  • The patient is not using the requested agent for treatment of wrinkles, stretch marks, age spots, or skin lightening AND
  • ONE of the following:
  • A. The patient is currently being treated with the requested agent and is stable on therapy [chart notes required] OR
  • B. The patient has tried and had an inadequate response to a generic topical retinoid [chart notes required] OR
  • C. A generic topical retinoid was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
  • D. The patient has an intolerance or hypersensitivity to a generic topical retinoid [chart notes required] OR
  • E. The patient has an FDA labeled contraindication to ALL generic topical retinoids [chart notes required] OR
  • F. A generic topical retinoid is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the drug, or would cause adherence barrier, worsen a comorbid condition, or cause adverse reaction/harm [chart notes required] OR
  • G. A generic topical retinoid is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • H. The patient has tried another prescription drug in the same pharmacologic class as a generic topical retinoid and discontinued due to lack of efficacy or adverse event [chart notes required]
  • If member resides in Ohio AND plan is Fully Insured or HIM Shop (SG), then BOTH of the following:
  • A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • B. ONE of the following:
  • 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 2. The patient has another indication that is supported in compendia (DrugDex level 1, 2A, 2B or AHFS-DI supportive narrative) OR
  • 3. The prescriber has submitted TWO major peer-reviewed journal articles supporting the proposed use (e.g., JAMA, NEJM, Lancet; RCT or double blind trials; case studies not acceptable)

Reauthorization criteria

  • Continuation may be approved if the patient continues to meet the above criteria and remains stable on therapy

Approval duration

12 months