Generic topical retinoids — Blue Cross Blue Shield of New Mexico

Initial criteria

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