Finacea foam — Medical Mutual
inflammatory lesions of rosacea
Preferred products
- generic azelaic acid gel 15%
- generic ivermectin cream 1%
- generic metronidazole cream 0.75%
- generic metronidazole gel 0.75% and 1%
- generic metronidazole lotion 0.75%
- Rosadan cream
- Rosadan gel
Initial criteria
- If the patient has tried one preferred product, then authorization for a non-preferred product may be given
Reauthorization criteria
- Approve for 1 year if the patient meets A, B, or C:
- 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 AND meets ONE of the following (i or ii):
- i. The patient has at least 130 days of prescription claims history on file supporting 90 days of use within 130-day look-back AND there is no generic equivalent available (AA-rated or AB-rated); OR
- ii. When 130 days of claims history is unavailable, prescriber must verify 90 days of use via paid claims (not samples/coupons) AND no generic equivalent available (AA-rated or AB-rated)
Approval duration
initial 730 days; extended 730 days; continuation 1 year