Evoclin — Cigna
acne vulgaris
Preferred products
- sodium sulfacetamide/sulfur 10%/5% emollient cream
- generic prescription topical adapalene products
- generic prescription topical benzoyl peroxide products
- generic prescription topical clindamycin products (other than generic Clindagel and clindamycin phosphate 1% foam)
- generic prescription topical dapsone products
- generic prescription topical erythromycin products
- generic prescription topical sodium sulfacetamide-containing products
Initial criteria
- Patient has tried one Step 1 Product (sodium sulfacetamide/sulfur 10%/5% emollient cream, generic prescription topical adapalene-, benzoyl peroxide-, clindamycin products other than generic Clindagel and clindamycin phosphate 1% foam, dapsone-, erythromycin-, or sodium sulfacetamide-containing products)
Approval duration
1 year