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Altreno (tretinoin) — Blue Cross Blue Shield of New Mexico

Treatment of acne vulgaris

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 currently stable on the requested agent [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 or cause barriers to care, worsen a comorbid condition, decrease functional ability, or cause an adverse reaction [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 or mechanism of action as a generic topical retinoid and discontinued due to lack of efficacy or adverse event [chart notes required]
  • Additional approval pathway:
  • 1. Member resides in Ohio AND
  • 2. Plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
  • A. Patient has no FDA labeled contraindications to the requested agent AND
  • B. ONE of the following:
  • 1. Patient has another FDA labeled indication for the requested agent and route OR
  • 2. Indication is supported in compendia for the requested agent and route OR
  • 3. Prescriber provides two major peer-reviewed journal articles supporting proposed use (accepted study designs include randomized, double-blind, placebo-controlled clinical trials; case studies not acceptable)

Approval duration

12 months