Skip to main content

Acne Oral Antibiotics – NC Standard

Commercial Policy
Version Date: April 2025

Restricted Product(s):

Restriction applies to brand and generic products

  • Doxycycline Products
    • Acticlate® (doxycycline hyclate)
    • Doryx®/Doryx MPC® (doxycycline hyclate DR)
    • Oracea (doxycycline DR)
  • Other Branded Products
    • Seysara™ (sarecycline HCl)
  • Minocycline Products
    • Coremino™ (minocycline HCl ER)
    • Emrosi (minocycline HCl ER)
    • Minolira™ (minocycline HCl ER biphasic release)
    • Solodyn® (minocycline HCl ER)
    • Ximino® (minocycline HCl ER)

FDA Approved Use:

  • For the treatment of multiple bacterial related conditions including but not limited to: acne, rosacea, rickettsia, sexually transmitted infections, in which penicillin is contraindicated, and anthrax infection.
  • See prescribing information for product specific indications. 

Criteria for Approval of Restricted Product(s):

  1. The patient is 12 years of age or older; AND
  2. The patient has a diagnosis of moderate to severe acne vulgaris or rosacea; AND
  3. The patient has tried and failed or has a clinical contraindication/intolerance to topical acne or rosacea treatments; AND 
  4. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 365 days (1 year)

References:

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation / Update Information:

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.

April 2025: Criteria change: Created NC Standard Policy. Oracea now restricted on Net Results. Removed brand Vibramycin from policy.

Dec 2024: Criteria update: Added new to market Emrosi to policy. 

April 2024: Criteria update: Updated doxycycline DR (authorized generic Oracea®) to (generic Oracea®) due to MSC switch to Y.

July 2023: Criteria change: Removed Minocin from policy (obsolete). Step requirement through unrestricted alternative removed from policy.

Jan 2023: Criteria update: Added AG Minolira to the policy. Decreased duration of approval to 1 year.

Aug 2021: Criteria update: Removed Targadox and doxycycline hyclate 50mg tablets (generic Targadox) from the policy due to MSC switch to Y.

Jan 2021: Criteria update: Added Minocycline HCl ER 55mg, 65mg, 80mg, 105mg, 115mg (generic Solodyn) to policy. Removed discontinued products from policy: Adoxa, Monodox, Soloxide.

Additional historical revisions available upon request from Corporate Pharmacy

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

Information in other languages: Español   中文   Tiếng Việt   한국어   Français   العَرَبِيَّة   Hmoob   ру́сский   Tagalog   ગુજરાતી   ភាសាខ្មែរ   Deutsch   हिन्दी   ລາວ   日本語

© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.