Winlevi — United Healthcare
acne vulgaris
Preferred products
- tretinoin (generic Retin-A)
- benzoyl peroxide/clindamycin (generic Duac)
- benzoyl peroxide/erythromycin (generic Benzamycin)
- dapsone (generic Aczone)
Initial criteria
- Diagnosis of acne vulgaris
- age ≥ 12 years
- History of failure, contraindication, or intolerance to an adequate trial of a topical retinoid (e.g. tretinoin (generic Retin-A))
- History of failure, contraindication, or intolerance to an adequate trial of a topical antibiotic in combination with benzoyl peroxide (e.g. benzoyl peroxide/clindamycin (generic Duac), benzoyl peroxide/erythromycin (generic Benzamycin))
- History of failure, contraindication, or intolerance to an adequate trial of a topical dapsone (e.g. generic Aczone)
Reauthorization criteria
- Documentation of positive clinical response to therapy
- Patient has been assessed for signs of hypothalamus-pituitary-adrenal (HPA) axis suppression (e.g. fatigue, weight loss, abdominal pain, depression, muscle weakness)
Approval duration
6 months