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
Last review date: June 21, 2020