Epiduo forte — Blue Cross Blue Shield of Oklahoma

Preferred products

• generic topical retinoids

Initial criteria

• Patient is not using the requested agent for treatment of wrinkles, stretch marks, age spots, or skin lightening AND
• ONE of the following: (A) Patient is currently being treated with the requested agent and is stable on therapy [chart notes required] OR (B) 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/effectiveness, diminished effect, or adverse event [chart notes required] OR (D) Patient has an intolerance or hypersensitivity to a generic topical retinoid [chart notes required] OR (E) 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 known clinical characteristics or cause significant barriers to care/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) Patient has tried another drug in the same pharmacologic class as a generic topical retinoid which was discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required]
• For members residing in Ohio with Fully Insured or HIM Shop (SG) plans: Patient does NOT have any FDA labeled contraindications to the requested agent AND ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication that is supported in compendia for the requested agent and route of administration OR (3) Prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as safe and effective

Approval duration

12 months