clascoterone cream 1% — Blue Cross Blue Shield of Texas

acne vulgaris

Initial criteria

Patient has a diagnosis of acne vulgaris AND ONE of the following: (a) tried and had inadequate response to at least ONE generic topical antibiotic agent used in the treatment of acne OR (b) tried and had inadequate response to at least ONE generic topical retinoid agent used in the treatment of acne OR (c) has intolerance or hypersensitivity to a generic topical antibiotic agent OR a generic topical retinoid therapy used in the treatment of acne OR (d) has an FDA labeled contraindication to ALL generic topical antibiotic agents AND generic topical retinoid agents used in the treatment of acne
If the patient has an FDA labeled indication, then ONE of the following: (a) age is within FDA labeling for the requested indication OR (b) there is support for use at the patient's age for the indication

Continuation of therapy: The prescriber states the patient has been treated with the requested agent (not including samples) within the past 90 days AND is at risk if therapy is changed

12 months