Absorica — Medical Mutual

Preferred products

• Claravis
• Myorisan
• Zenatane
• Amnesteem
• Accutane
• Isotretinoin capsules (all generic isotretinoin products (authorized and true))

Initial criteria

• Patient has tried a preferred medication; OR
• Patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents; OR
• Patient has a contraindication to all preferred agents; OR
• Patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
• - Patient has at least 130 days of prescription claims history on file and claims history supports that the patient has received the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested nonpreferred product (i.e. AA-rated or AB-rated to the requested nonpreferred product); OR
• - When 130 days of the patient’s prescription claims history file is unavailable for verification, the prescriber must verify that the patient has been receiving the requested non-preferred agent for 90 days AND that the patient has been receiving the requested non-preferred agent via paid claims (i.e. the patient has NOT been receiving samples or coupons or other types of waivers in order to obtain access to the requested non-preferred agent) AND there is no generic equivalent available for the requested nonpreferred product (i.e. AA-rated or AB-rated to the requested nonpreferred product).

Reauthorization criteria

• Continuation of therapy is approved for 1 year if initial criteria are met.

Approval duration

1 year