DIFFERIN (adapalene)

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.