AKLIEF (trifarotene)

AKLIEF (trifarotene)

SELF ADMINISTRATION- TOPICAL 

Indications for prior authorization: 

• Treatment of acne vulgaris in patients 9 years of age and older

Prior authorization criteria:

• Patient is ≥ 9 years of age; AND
• 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; AND
  • Topical tretinoin

The following conditions do not meet the criteria for use as established by WHA P&T committee:

• Cosmetic use

Approval:

•  1 year