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: June 5, 2017