Tretinoin (Retin-A)

SELF ADMINISTRATION - TOPICAL

FDA Approved Indications:

  • Acne vulgaris
  • Avita, Retin-A, and Retin-A Micro are all indicated for the treatment of acne vulgaris

Prior authorization criteria:

  • Patient is > 30 years old AND
  • Diagnosis of acne vulgaris (supported by chart note documentation) AND
  • Failure to respond to the 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; AND
    • For Retin-A Micro (topical tretinoin microsphere): in addition to failing the above medications, patients must also fail tretinoin non-mincrosphere

Approval: 

One Year


 

Last review date: July 25, 2016