Prior authorization criteria for:
Avita®,
Retin-A®
COVERED USES:
FDA Approved Indications: Mild to moderate acne vulgaris
All FDA-approved indications not otherwise excluded from Part D.
Off-Label Uses: Mild to moderate psoriasis and early actinic keratosis.
AGE RESTRICTIONS:
NA
PRESCRIBER RESTRICTIONS:
NA
REQUIRED MEDICAL INFORMATION:
For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.
CRITERIA:
The condition being treated meets the "Covered Uses" criteria above.
EXCLUSION CRITERIA:
Cosmetic use and treatment of Rosacea.
COVERAGE DURATION:
Initial authorization and reauthorization will be approved for up to one year.