Acne Oral Antibiotics - Net Results

• Doxycycline Products
  • Acticlate® (doxycycline hyclate)
  • Doryx®/Doryx MPC® (doxycycline hyclate DR)
  • doxycycline hyclate 75 mg tablet (generic Acticlate®)
  • doxycycline hyclate 150 mg tablet (generic Acticlate®)
  • doxycycline hyclate tab ER (generic Doryx®)
  • doxycyline hyclate tab DR 80mg tablet
  • Vibramycin® (doxycycline monohydrate)
• Minocycline Products
  • Coremino™ (minocycline HCl ER)
  • Minocycline HCl ER 45 mg, 90 mg, 135 mg tablets (generic Coremino™)
  • Emrosi (minocycline HCl ER)
  • minocycline HCl ER 55 mg, 65 mg, 80 mg, 105 mg, 115 mg (generic Solodyn®)
  • Minocycline HCl ER 45 mg, 90 mg, 135 mg capsules (authorized generic Ximino®)
  • Minocycline HCl ER biphasic release (authorized generic Minolira™)
  • Minolira™ (minocycline HCl ER biphasic release)
  • Solodyn® (minocycline HCl ER)
  • Ximino® (minocycline HCl ER)
• Other Branded Products
  • Seysara™(sarecycline HCl)

• 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. 

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 products that require Value PA, refer to the Value PA UM Criteria

Duration of Approval: 365 days (1 year)

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

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.

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

Nov 2023: Criteria update: Updated terminology from Medical Necessity PA to Value PA.

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

Feb 2023: Criteria update: Removed Oracea and doxycycline delayed release 40mg capsules (authorized generic Oracea) from the 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.

Mar 2020: Criteria update: Added Minocycline HCL ER 45 mg, 90 mg, 135 mg capsules (authorized generic Ximino) to the policy.

Jan 2020: Criteria update: Removed unrestricted/suggested alternatives.

Jun 2019: Authorized generic for Oracea, Doxycycline 50mg tablet, Coremino, Acticlate & Soloxide added to restricted section.

Apr 2019: added new to market doxycycline hyclate delayed release 80 mg tablet to the criteria.

Apr 2019: added restrictions to doxycycline 75 mg, 150mg (Acticlate), doxycycline ER (Doryx), and minocycline ER 45 mg, 90 mg, 135 mg. Solodyn added as an unrestricted alternative. Changed requirements for “generics” to “alternatives.”

Feb 2019: added new to market generics minocycline ER 80 & 105mg tablets to unrestricted section, as well as other generic unrestricted Solodyn strengths.

Jan 2019: added new to market Seysara to the policy.

Oct 2018: added new to market Minolira to restricted products.

Oct 2017: added new to market Ximino to restricted products Jun 2017: reformatted criteria; no change to policy; brand Dynacin removed, no longer on the market.

May 2017: added minocycline er 45mg to restriction due to sole manufacturer in the market.

Jan 2017: separated policy for Net Results formulary; removed preferred brands.

Oct 2016: Reviewed for Essential Formulary; non-formulary verbiage added. Removed non-FDA approved products. Added new to market drug Doryx MPC.

Jul 2015: Added new to market drug Targadox.

Jan 2011: Original utilization management criteria issued.