Brand name topical acne cleansers containing benzoyl peroxide or sulfacetamide/sulfur — Medical Mutual

Preferred products

• Generic prescription topical acne cleansers containing benzoyl peroxide or sulfacetamide/sulfur

Initial criteria

• If the patient has tried a preferred product, approve a non-preferred product
• Step Therapy Exception: Approve if ANY of the following:
• A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents [documentation required]; OR
• B. The patient has a contraindication to all preferred agents [documentation required]; OR
• C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days [verification required] AND meets ONE of the following:
• 1. Patient has at least 130 days of prescription claims history and received requested non-preferred agent for 90 days within that period AND there is no generic equivalent available (AA-rated or AB-rated); OR
• 2. If 130 days of claims history is unavailable, prescriber must verify patient was receiving requested non-preferred agent for 90 days via paid claims (not samples, coupons, or waivers) AND no generic equivalent available (AA-rated or AB-rated).

Approval duration

2 years initial; 2 years extended; 1 year for exception criteria