Dapsone topical (Aczone)

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: May 9, 2017