The following products are included in this PA program (formulary specific):
Basic formulary: Avita 0.025% cream, Avita 0.025% gel, tazarotene 0.1% cream, Tazorac 0.05% cream, tazarotene 0.05% cream, tretinoin 0.025% cream, tretinoin 0.05% cream, tretinoin 0.1% cream, tretinoin 0.01% gel, tretinoin 0.025% gel
MAPD Classic and HC Enhanced formularies: Avita 0.025% cream, Avita 0.025% gel, tazarotene 0.1% cream, Tazorac 0.05% cream, tazarotene 0.05% cream, tazarotene 0.05% gel, tazarotene 0.1% gel, tretinoin 0.025% cream, tretinoin 0.05% cream, tretinoin 0.1% cream, tretinoin 0.01% gel, tretinoin 0.025% gel
Prior Authorization Criteria for Approval
The requested medication will be approved when BOTH of the following are met:
- The requested medication will NOT be used for cosmetic purposes
AND - ONE of the following:
- The patient has an FDA labeled indication for the requested medication
OR - The patient has an indication that is supported in CMS approved compendia for the requested medication
- The patient has an FDA labeled indication for the requested medication
Length of Approval: 12 months
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