WHA
 

Oral Brand Tetracyclines

Indications for Prior Authorization

Criteria

Avidoxy, Doryx MPC*, Doxycycline Hyclate DR, Emrosi, Mondoxyne NL, Oracea, brand Targadox, brand Vibramycin

Step Therapy

Length of Approval: 12 Month(s)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure (of a minimum 30-day supply) within the past 180 days or intolerance to one of the following generics:
    • doxycycline
    • minocycline
Seysara

Step Therapy

Length of Approval: 12 Month(s)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure (of a minimum 30-day supply) within the past 180 days or intolerance to BOTH of the following generics:
    • doxycycline
    • minocycline

  • Guideline ID
    GL-514234

  • Formulary
    premium

  • Effective date
    Apr 1, 2026

  • P&T approval date
    Feb 16, 2010

P & T Revisions

2026-02-04, 2025-12-18, 2025-12-18, 2025-01-23, 2025-01-02, 2024-12-06, 2024-11-27, 2024-10-23, 2024-03-01, 2024-02-19

  1. Doryx MPC Prescribing Information. Mayne Pharma. Greenville, NC. May 2023.
  2. Seysara Prescribing Information. Almirall, LLC. Exton, PA. March 2023.
  3. Vibramycin Prescribing Information. Pfizer Labs. New York, NY. April 2021.
  4. Targadox Prescribing Information. Journey Medical Corporation. Scottsdale, AZ. July 2020.
  5. Oracea Prescribing Information. Galderma Laboratories, L.P. Forth Worth TX. January 2023.
  6. Solodyn Prescribing Information. Valeant Pharmaceuticals North America LLC. Bridgewater, NJ. December 2022.
  • 2026-02-04: 2026 Annual Review. No clinical criteria changes. Background updates including removal of obsolete products.
  • 2025-12-18: No criteria changes
  • 2025-12-18: no criteria changes, added IL statute operational note
  • 2025-01-23: 2025 Annual Review. Background updates only.
  • 2025-01-02: Added Emrosi as target to the guideline.
  • 2024-12-06: Update to product name section.
  • 2024-11-27: Moved Mondoxyne 100mg capsule and Avidoxy 100mg tabs GPIs to correct criteria bucket.
  • 2024-10-23: Add Mondoxyne 100mg capsule and Avidoxy 100mg tabs as targets to Oral Brand Tetracyline ST guideline.
  • 2024-03-01: Revised change to add Seysara to first criteria bucket.
  • 2024-02-19: 2024 Annual Review. Replacing GL-119938 due to UMCS error - indications moved to background section. Removed obsolete GPIs and updated references. Added Seysara to first criteria bucket, as it matches the criteria.