tretinoin-benzoyl peroxide — Blue Cross Blue Shield of Montana

Initial criteria

• The patient is not using the requested agent for treatment of wrinkles, stretch marks, age spots, or skin lightening
• 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