Topical Retinoid Agents
Indications for Prior Authorization
Atralin (tretinoin), Avita (tretinoin) cream and gel, Retin-A (tretinoin) cream and gel, Retin-A Micro (tretinoin) gel
-
For diagnosis of Acne vulgaris
Indicated for the topical treatment of acne vulgaris. -
For diagnosis of Wound healing (mild) [9]
Tretinoin 0.05% cream has been shown to decrease would healing time in patients receiving electroepilation. Enhanced healing of epidermal wounds in patients undergoing dermabrasion when pretreated with tretinoin 0.05% cream has been reported. DRUGDEX Recommendation: Adult, Class IIb, Evidence favors efficacy. -
Actinic keratosis [9]
-
Hyperkeratosis [9]
-
Keloid scar [9]
Aklief (trifarotene) cream, Arazlo (tazarotene) lotion
-
For diagnosis of Acne vulgaris
Indicated for the topical treatment of acne vulgaris in patients 9 years of age and older.
Altreno (tretinoin) lotion
-
For diagnosis of Acne vulgaris
Indicated for the topical treatment of acne vulgaris in patients 9 years of age and older. -
For diagnosis of Wound healing (mild) [9]
Tretinoin 0.05% cream has been shown to decrease would healing time in patients receiving electroepilation. Enhanced healing of epidermal wounds in patients undergoing dermabrasion when pretreated with tretinoin 0.05% cream has been reported. DRUGDEX Recommendation: Adult, Class IIb, Evidence favors efficacy. -
Actinic keratosis [9]
-
Hyperkeratosis [9]
-
Keloid scar [9]
Differin (adapalene) cream/lotion/gel/solution/pads
-
For diagnosis of Acne vulgaris
Indicated for the topical treatment of acne vulgaris.
Tazorac (tazarotene) cream 0.1%
-
For diagnosis of Acne Vulgaris
Indicated for the topical treatment of patients with acne vulgaris. -
For diagnosis of Plaque Psoriasis
Indicated for the topical treatment of patients with plaque psoriasis.
Tazorac (tazarotene) cream 0.05%
-
For diagnosis of Plaque Psoriasis
Indicated for the topical treatment of patients with plaque psoriasis.
Tazorac (tazarotene) gel 0.1%
-
For diagnosis of Acne Vulgaris
Indicated for the topical treatment of patients with facial acne vulgaris of mild to moderate severity. -
For diagnosis of Plaque Psoriasis
Indicated for the topical treatment of patients with plaque psoriasis of up to 20% body surface area involvement.
Tazorac (tazarotene) gel 0.05%
-
For diagnosis of Plaque Psoriasis
Indicated for the topical treatment of patients with plaque psoriasis of up to 20% body surface area involvement.
Fabior (tazarotene) foam
-
For diagnosis of Acne Vulgaris
Indicated for the topical treatment of acne vulgaris in patients 12 years of age or older.
Criteria
Avita, Brand Retin A Micro (0.06%, 0.08%)
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Acne Vulgaris
- One of the following:
- Patient is 25 years of age or younger OR
- Both of the following:
- Patient is older than 25 years of age
- Diagnosis of acne vulgaris (i.e., acne)
Aklief, Altreno, Atralin, Brand Retin-A, Brand Retin-A Micro (0.1% 0.04%), Brand Adapalene 0.1% Soln, Brand Adapalene 0.1% Pads
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Acne Vulgaris
- One of the following:
- Both of the following:
- Patient is 25 years of age or younger AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to BOTH of the following generics:
- Adapalene (cream, gel)
- Topical tretinoin or tretinoin microsphere
- All of the following:
- Patient is older than 25 years of age AND
- Diagnosis of acne vulgaris (i.e., acne) AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to BOTH of the following generics:
- Adapalene (cream, gel)
- Topical tretinoin or tretinoin microsphere
Avita, Brand Retin A Micro (0.06%, 0.08%)
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Other Medical Uses (Off-Label)
- One of the following diagnoses: [A, 9]
- Actinic keratosis
- Hyperkeratosis
- Keloid scar
- Wound healing (mild)
Altreno, Atralin, Brand Retin-A, Brand Retin-A Micro (0.04%, 0.1%)
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Other Medical Uses (Off-Label)
- One of the following diagnoses: [A, 9]
- Actinic keratosis
- Hyperkeratosis
- Keloid Scar
- Wound healing (mild)
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to any generic topical tretinoin product
Brand Differin
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Acne Vulgaris
- One of the following:
- Both of the following:
- Patient is 25 years of age or younger AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to BOTH of the following generics:
- adapalene (cream, gel)
- Topical tretinoin or tretinoin microsphere
- All of the following:
- Patient is older than 25 years of age AND
- Diagnosis of acne vulgaris (i.e., acne) AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to BOTH of the following generics:
- adapalene (cream, gel)
- Topical tretinoin or tretinoin microsphere
Arazlo, Fabior, Brand Tazarotene 0.1% foam, Brand Tazorac 0.1% cream and gel
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Acne Vulgaris
- One of the following:
- Both of the following:
- Patient is 25 years of age or younger AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication or intolerance to BOTH of the following:
- generic tazarotene AND
- One of the following:
- generic adapalene
- generic topical tretinoin or tretinoin microsphere
- All of the following:
- Patient is older than 25 years of age AND
- Diagnosis of acne vulgaris (i.e., acne) AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication or intolerance to BOTH of the following:
- generic tazarotene AND
- One of the following:
- generic adapalene
- generic topical tretinoin or tretinoin microsphere
Brand Tazorac
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Plaque Psoriasis
- Diagnosis of plaque psoriasis AND
- Both of the following:
- Trial and failure (of a minimum 30-day supply) within the past 180 days, or intolerance to generic tazarotene AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to one medium to high potency topical corticosteroid (e.g., triamcinolone, fluocinonide)
Generic tazarotene 0.1% cream, generic tazarotene 0.1% gel, generic tazarotene 0.05% gel
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Plaque Psoriasis
- Diagnosis of plaque psoriasis AND
- Trial and failure (of a minimum 30-day supply) within the past 180 days, contraindication, or intolerance to one medium to high potency topical corticosteroid (e.g., triamcinolone, fluocinonide)
Generic tazarotene 0.1% cream, generic tazarotene 0.1% gel
Treatment for cosmetic purposes (i.e., wrinkles, senile lentigo, solar elastosis, dyschromia, melasma or chloasma, hyperpigmentation of skin, facial mottling) is a benefit exclusion. [A]
Prior Authorization
Length of Approval: 12 Month(s)
For diagnosis of Acne Vulgaris
- One of the following:
- Patient is 25 years of age or younger OR
- Both of the following:
- Patient is older than 25 years of age
- Diagnosis of acne vulgaris (i.e., acne)
P & T Revisions
2023-06-29, 2023-05-26, 2023-01-31, 2022-10-04, 2021-12-17, 2021-09-28, 2021-06-04, 2021-05-17, 2021-02-04, 2020-10-21, 2020-09-18, 2020-04-01, 2019-10-30, 2019-07-26
References
- Adapalene Topical Solution 0.1% Prescribing Information. Allegis Holdings LLC. Canton, MS. December 2020.
- Aklief Prescribing Information. Galderma Laboratories, L.P. Fort Worth, Texas. January 2022.
- Altreno Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. March 2020.
- Atralin Prescribing Information. Valeant Pharmaceuticals. Bridgewater, NJ. July 2016.
- Avita Prescribing Information. Mylan Pharmaceuticals Inc. Morgantown, WV. June 2018.
- Differin Prescribing Information. Galderma Laboratories, L.P. Fort Worth, TX. June 2021.
- Retin-A Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. September 2019.
- Retin-A Micro Prescribing Information. Valeant Pharmaceuticals. Bridgewater, NJ. October 2017.
- DRUGDEX System [Internet database]. Greenwood Village (CO): IBM Corporation; Updated periodically. Available by subscription at: www.micromedexsolutions.com. Accessed September 14, 2022.
- Per clinical consult with dermatologist, June 7, 2012.
- Fabior Prescribing Information. Mayne Pharma. Greenville, NC. June 2018.
- Tazorac Prescribing Information. Allergan, Inc. Irvine, CA. July 2017.
- Arazlo Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. May 2021.
- Menter A, Korman N, Elmets C, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Amer. Acad. of Derm. 2009;60:643-59.
- UptoDate Online [internet database]. Waltham, MA. UptoDate, Inc. Updated periodically. Available by subscription at: www.uptodate.com. Accessed September 14, 2022.
End Notes
- The use of topical retinoids for the following conditions was clarified as either medical or cosmetic (plan exclusions). [10] Please refer to Background section for table with details.
Revision History
- 2023-06-29: Removed generic adapalene cream, gel, and pump as targets from guideline.
- 2023-05-26: Separated guideline for EHB due to OptumRx standard having separate formulary strategy for Aklief
- 2023-01-31: Removed generic tretinoin and generic tretinoin microsphere products as targets from guideline. Updated background.
- 2022-10-04: Annual review - updated background table and references. Added generic tazarotene 0.05% and 0.1% gel to guideline.
- 2021-12-17: Annual review - Updated background and references. Removed obsolete adapalene lotion as target and as ST option.
- 2021-09-28: Updated GPIs for Fabior criteria section.
- 2021-06-04: Updated GPIs for Fabior criteria section.
- 2021-05-17: Added new authorized brand alternative for Fabior with criteria to mirror Fabior. Added EHB formulary.
- 2021-02-04: Added Arazlo to guideline mirroring Fabior. Added T/F requirement through topical corticosteroids for brand Tazorac and generic tazarotene for plaque psoriasis. Updated background and references.
- 2020-10-21: Annual review - no changes (previous criteria changes will be effective 1/1/2021)
- 2020-09-18: Added criteria for Differin, Tazorac and Fabior. Embedded ST will apply to all ages. Diagnosis criterion will only apply to patients older than 25 years of age for acne vulgaris. Updated background and references.
- 2020-04-01: Brand Retin-A Micro 0.08% and 0.06% moved to section with only diagnosis requirement
- 2019-10-30: Added new product Aklief. Added an embedded step through generic adapalene for brand Differin. Removed obsolete products Plixda and Tretin-X. Updated background and references.
- 2019-07-26: June P&T autoupdate to add brand Retin-A micro as a ST target. No changes to clinical criteria. XC 7/26/19.
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