CABTREO (clindamycin/adapalene/benzoyl peroxide)

CABTREO (clindamycin/adapalene/benzoyl peroxide)

Self-Administration – topical gel

Diagnosis considered for coverage:

• Acne Vulgaris: Indicated for the topical treatment of acne vulgaris in adult and pediatric patients 12 years of age and older

Coverage Criteria:

For diagnosis of acne vulgaris:

• Patient is 12 years of age or older; AND
• Patient has a diagnosis of acne vulgaris; AND
• Prescribed by or in consultation with a dermatologist; AND
• Documentation  of a medical reason why the patient cannot take benzoyl peroxide, adapalene, and topical clindamycin concurrently as individual agents; AND
• Medical records confirm trial and failure, contraindication, or intolerance to ALL of the following:
  • A topical benzoyl peroxide product
  • A topical adapalene-containing or tretinoin-containing product
  • A topical prescription strength antibiotic (e.g., clindamycin, erythromycin)

Reauthorization Criteria:

For diagnosis of acne vulgaris:

• Documentation of a positive clinical response to therapy

Coverage Duration: 

• Initial: 1 year
• Reauthorization: 1 year

Dosing:

• Apply a thin layer of CABTREO to the affected areas once daily.
• Avoid the eyes, mouth, paranasal creases, mucous membranes, and areas of broken, eczematous, or sunburned skin.

Authorization is not covered for the following:

• The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• CABTREO is the first and only FDA-approved fixed-dose, triple-combination topical treatment for acne. It contains 1.2% clindamycin phosphate, 0.15% adapalene, and 3.1% benzoyl peroxide.
• Clindamycin can cause severe colitis, which may result in death. Discontinue CABTREO if diarrhea occurs
• Use CABTREO with caution in patients receiving neuromuscular blocking agents

Policy Updates:

• 09/01/2024 – New policy for Cabtreo approved by WHA P&T Committee. (P&T, 08/20/2024)

References:

1. Cabtreo Prescribing Information. Bausch Health Companies Inc., Bridgewater, NJ. October 2023.