Cleocin T (clindamycin phosphate 1% topical lotion – Pfizer, generic) — Cigna

Initial criteria

• If the patient needs to treat acne on greater than 8% of their body surface area, approve the requested quantity not to exceed:
• • For Cleocin T (clindamycin phosphate 1% lotion, generic): 240 mL per 30 days at retail or 720 mL per 90 days at home delivery.
• • For clindamycin phosphate 1% gel (generic only to formerly available Cleocin T gel): 240 grams per 30 days at retail or 720 grams per 90 days at home delivery.
• • For clindamycin phosphate 1% solution (generic only to formerly available Cleocin T solution): 240 mL per 30 days at retail or 720 mL per 90 days at home delivery.
• • For Clindagel (clindamycin phosphate 1% gel, generic): 300 mL per 30 days at retail or 900 mL per 90 days at home delivery.
• • For Evoclin (clindamycin phosphate 1% foam, generic): 200 grams per 30 days at retail or 600 grams per 90 days at home delivery.

Approval duration

1 year