Adapalene (Differin)

SELF-ADMINISTRATION - TOPICAL

FDA Approved Indications:

  • Acne vulgaris

Authorization NOT Allowed for the following:

  • Differin OTC

Prior authorization criteria:

  • 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

Last review date: May 9, 2017