AKLIEF (trifarotene)
SELF ADMINISTRATION- TOPICAL
Indications for prior authorization:
- Treatment of acne vulgaris in patients 9 years of age and older
Prior authorization criteria:
- Patient is ≥ 9 years of age; 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
- Topical tretinoin
The following conditions do not meet the criteria for use as established by WHA P&T committee:
- Cosmetic use
Approval:
- 1 year
Last review date: February 18, 2020