Absorica LD — United Healthcare
treatment resistant acne
Preferred products
- Claravis
- Myorisan
- Zenatane
- Amnesteem
- isotretinoin 10 mg
- isotretinoin 20 mg
- isotretinoin 30 mg
- isotretinoin 40 mg
Initial criteria
- Submission of medical records documenting one of the following: (1) Diagnosis of severe recalcitrant nodular acne unresponsive to conventional therapy OR (2) Diagnosis of treatment resistant acne
- AND History of failure, contraindication, or intolerance to an adequate trial of two of the following conventional therapy regimens: (1) Topical retinoid or retinoid-like agent (e.g., tretinoin) OR (2) Oral antibiotic (e.g., erythromycin, minocycline) OR (3) Topical antibiotic with or without benzoyl peroxide (e.g., clindamycin, erythromycin, benzoyl peroxide/clindamycin, benzoyl peroxide/erythromycin)
- AND History of failure, contraindication, or intolerance to an adequate trial on two oral isotretinoin formulations (document duration of trial): Claravis, Myorisan, Zenatane, Amnesteem, or isotretinoin 10 mg, 20 mg, 30 mg, or 40 mg
Reauthorization criteria
- After ≥ 2 months off therapy, persistent or recurring severe recalcitrant nodular acne is still present OR
- Total cumulative dose for total duration of therapy is less than 150 mg/kg (will be approved up to a total of 150 mg/kg)
Approval duration
6 months