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

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