Sodium sulfacetamide — Medical Mutual
Mild to moderate acne rosacea
Preferred products
- Generic prescription topical acne products containing adapalene
- Generic prescription topical acne products containing benzoyl peroxide
- Generic prescription topical acne products containing clindamycin (other than generic Clindagel)
- Generic prescription topical acne products containing dapsone
- Generic prescription topical acne products containing erythromycin
- Generic prescription topical acne products containing sodium sulfacetamide
- Generic prescription topical acne products containing sodium sulfacetamide/sulfur
- Aczone 7.5% gel (counts as preferred when DAW9)
- Onexton (counts as preferred when DAW9)
Initial criteria
- If the patient has tried a preferred product, approve a non-preferred product.
Reauthorization criteria
- Continuation of therapy approvals are provided for 1 year unless otherwise noted.
Approval duration
initial 2 years; reauth 2 years; continuation 1 year