Pharmacy Prior Authorization Criteria

Oral Brand Tetracyclines

Indications for Prior Authorization

Criteria

Acticlate*, Avidoxy, Doryx, Doryx MPC*, Doxycycline Hyclate DR, LymePak, Minolira, Mondoxyne NL, Oracea, brand Solodyn, brand Targadox, brand Vibramycin

*Product may be excluded depending on the plan.

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply) within the past 180 days or intolerance to one of the following generics:
• doxycycline
• minocycline

Seysara

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply) within the past 180 days or intolerance to BOTH of the following generics:
• doxycycline
• minocycline

P & T Revisions

2024-12-06, 2024-11-27, 2024-10-23, 2024-03-01, 2024-02-19

References

1. Acticlate Prescribing Information. Aqua Pharmaceuticals. Exton, PA. October 2017.
2. Doryx Prescribing Information. Mayne Pharma. Greenville, NC. July 2022
3. Doryx MPC Prescribing Information. Mayne Pharma. Greenville, NC. June 2023.
4. Seysara Prescribing Information. Almirall, LLC. Exton, PA. March 2023.
5. Vibramycin Prescribing Information. Pfizer Labs. New York, NY. April 2021.
6. Minolira Prescribing Information. EPI Health, Inc. Charleston, SC. June 2018.
7. Targadox Prescribing Information. Journey Medical Corporation. Scottsdale, AZ. July 2020.
8. Oracea Prescribing Information. Galderma Laboratories, L.P. Forth Worth TX. January 2023.
9. Solodyn Prescribing Information. Valeant Pharmaceuticals North America LLC. Bridgewater, NJ. December 2022.
10. LymePak Prescribing Information. Chartwell Pharmaceuticals, LLC. Congers, NY. November 2021.

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Revision History

• 2024-12-06: Update to product name section.
• 2024-11-27: Moved Mondoxyne 100mg capsule and Avidoxy 100mg tabs GPIs to correct criteria bucket.
• 2024-10-23: Add Mondoxyne 100mg capsule and Avidoxy 100mg tabs as targets to Oral Brand Tetracyline ST guideline.
• 2024-03-01: Revised change to add Seysara to first criteria bucket.
• 2024-02-19: 2024 Annual Review. Replacing GL-119938 due to UMCS error - indications moved to background section. Removed obsolete GPIs and updated references. Added Seysara to first criteria bucket, as it matches the criteria.

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