Avita — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when the patient has a diagnosis of acne vulgaris
• Authorization may be granted when the patient has a diagnosis of keratosis follicularis (Darier’s disease, Darier-White disease)

Reauthorization criteria

• Acne vulgaris: Authorization may be granted when the patient has a diagnosis of acne vulgaris when the following criteria is met: The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions, patient satisfaction, etc.)
• Keratosis follicularis: Authorization may be granted when the patient has a diagnosis of keratosis follicularis (Darier’s disease, Darier-White disease) when the following criteria is met: The patient has achieved or maintained a positive clinical response as evidenced by improvement

Approval duration

Initial therapy: 4 months; Continuation of therapy: 36 months (reference 355-A) or 12 months (reference 237-A)