DIFFERIN (adapalene)

SELF-ADMINISTRATION - TOPICAL

FDA Approved Indications:

  • Acne vulgaris

Authorization NOT Allowed for the following:

  • Differin OTC

Prior authorization criteria:

  • Criteria applicable for the 0.1% strength:

    • Diagnosis of acne vulgaris (supported by chart note documentation); AND
    • Failure to respond to the following (supported by chart note documentation):
      • Differin OTC (0.1% gel)
  • Criteria applicable for the 0.3% strength

    • Patient is > 30 years old
    • 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 (0.1% gel)

Approval:

  • One year

Review/Update:

  • 05/09/2017 - Initial review.
  • 08/18/2020 - Annual review.
  • 01/12/2021 - Update to format, added criteria for all strengths.

Last review date: January 13, 2021

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