Cleocin-T gel — CareFirst (Caremark)

Initial criteria

• The requested drug is being prescribed for the topical treatment of acne vulgaris
• The requested drug is NOT being used in a footbath

Reauthorization criteria

• The requested drug is being prescribed for the topical treatment of acne vulgaris
• The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions, patient satisfaction, etc.)
• The requested drug is NOT being used in a footbath

Approval duration

Initial therapy: 4 months; Continuation of therapy: 12 months