generic topical retinoids — Blue Cross Blue Shield of Oklahoma
acne or other FDA labeled indications for topical retinoids
Initial criteria
- Patient is not using the requested agent for treatment of wrinkles, stretch marks, age spots, or skin lightening
- 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