Isotretinoin (Claravis, Amnesteem, Myorisan, Zenatane, Absorica®)

SELF-ADMINISTRATION - ORAL

FDA Approved Indications:
  • Severe recalcitrant nodular acne

Authorization Not Allowed for the following:
  • All non-FDA approved uses not listed in the approved indications

Prior authorization criteria:
  • Diagnosis of severe nodular acne (supported by chart note documentation), AND
  • Patient's current weight required (as drug is weight based); isotretinoin should be appropriately dosed based off age and weight, AND
  • Isotretinoin should be used with extreme caution in patients with a history of psychiatric disorder
  • For Absorica®: all the previous criteria apply plus chart note documentation must support that the patient has a medical need to consume a very low fat diet
Approval:
  • Limited to a 5 month treatment course (at least two months must elapse before another treatment course may be considered)

Last review date: August 10, 2020

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