isotretinoin 35 mg (generic Absorica) — United Healthcare

treatment resistant acne

Preferred products

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

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)

6 months