RETIN-A (tretinoin)

RETIN-A (tretinoin)

SELF ADMINISTRATION - TOPICAL

FDA Approved Indications:

• Acne vulgaris
• Avita, Retin-A, and Retin-A Micro are all indicated for the treatment of acne vulgaris

Prior authorization criteria:

• Patient is > 30 years old AND
• Diagnosis of acne vulgaris (supported by chart note documentation) AND
• Failure to respond to the following (supported by chart note documentation):
  • Prescription strength topical antibiotics (e.g., clindamycin, erythromycin).  NOTE: if patient has non-inflammatory acne, prescription strength topical antibiotics are not required; AND
  • Differin OTC; AND
  • For Retin-A Micro (topical tretinoin microsphere): in addition to failing the above medications, patients must also fail tretinoin non-microsphere

Approval: 

One Year