ACZONE (dapsone)
SELF-ADMINISTRATION - TOPICAL
FDA Approved Indications:
- Acne vulgaris
Prior authorization criteria:
- Diagnosis of acne vulgaris (supported by chart note documentation) AND
- Failure to respond to the following (supported by chart note documentation):
- At least 2 prescription-strength topical antibiotics (e.g., clindamycin, erythromycin); AND
- Concomitant Differin OTC (using concomitantly as documented by chart notes)
Approval
- One year
Last review date: July 30, 2020