Finacea gel — Medical Mutual

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