Under some plans, including plans that use an open or closed formulary, Avita, Retin-A, Retin-A Micro and tretinoin are subject to precertification for members equal to or greater than 35 years of age.   If precertification requirements apply Aetna considers Avita, Retin-A and tretinoin to be medically necessary for those members who meet any of the following precertification criteria:

A.  A documented diagnosis of acne vulgaris

OR

B.   A documented diagnosis of actinic keratoses

AND

• Lesions are on the face OR
• Lesions are not on the face and therapy includes the use of 5-fluorouracil in conjunction with tretinoin

OR

C.  A documented diagnosis of hypertrophic scars or keloids AND intralesional injection of corticosteroids is ineffective or not tolerated

OR

D.  A documented diagnosis of keratosis follicularis (Darier's disease, Darier-White disease)

OR

E.   A documented diagnosis of facial flat warts

OR

F.   A documented diagnosis of multiple flat warts
 

Note:  Topical tretinoin is not covered for treatment of basal cell carcinoma, lichen planus, or dysplastic nevi because its use in these conditions is not supported by the peer-reviewed medical literature.

Akne-mycin, Azelex, Benzaclin, Benzagel, Benzamycin, Benziq, Binora, Brevoxyl, Brevoxyl-4/Brevoxyl-8, Cleocin-T, Clinac BPO, Differin, Duac, Evoclin, Inova, Inova 8/2 Acne Control, Klaron, Neobenz, Panretin, Retin-A, Retin-A Micro, Triaz3%, Triaz 6%, Triaz 9%, Z-Clinz, Ziana and Zoderm are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.*  Therefore, they are excluded from coverage for members enrolled in prescription drug benefits plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Akne-mycin, Azelex, Benzaclin, Benzagel, Benzamycin, Benziq, Binora, Brevoxyl, Brevoxyl-4/Brevoxyl-8,  Cleocin-T, Clinac BPO, Differin, Duac, Evoclin, Inova, Inova 8/2 Acne Control, Klaron, Neobenz,  Panretin, Retin-A, Retin-A Micro, Triaz3%, Triaz 6%, Triaz 9%, Z-Clinz, Ziana and Zoderm to be medically necessary for those members who meet any of the following criteria:

For Akne-Mycin and Benzamycin

A. A documented

• Contraindication to two covered alternatives indicated for the member's condition, one of which is erythromycin OR
• Intolerance to two covered alternatives indicated for the member's condition, one of which is erythromycin OR
• Allergy to two covered alternatives indicated for the member's condition, one of which is erythromycin OR
• Failure of an adequate trial of one month each of two covered alternatives indicated for the member's condition, one of which is erythromycin

For Benzaclin, Cleocin-T, Duac, Evoclin and Z-Clinz

A.  A documented:

• Contraindication to two covered alternatives indicated for the member's condition, one of which is clindamycin OR,
• Intolerance to two covered alternatives indicated for the member's condition, one of which is clindamycin OR,
• Allergy to two covered alternatives indicated for the member's condition, OR
• Failure of an adequate trial of one month each of two covered alternatives indicated for the member's condition, one of which is clindamycin

For Azelex, Benzagel, Benziq, Binora, Brevoxyl, Brevoxyl-4/Brevoxyl-8, Clinac BPO, Inova, Inova 8/2 Acne Control, Klaron, Neobenz, Panretin, Triaz 3%, Triaz 6%, Triaz 9% and Zoderm

A. A documented:

• Contraindication to two covered alternatives indicated for the member's condition OR,
• Intolerance to two covered alternatives indicated for the member's condition OR,
• Allergy to two covered alternatives indicated for the member's condition, OR
• Failure of an adequate trial of one month each of two covered alternatives indicated for the member's condition.

For Differin, Retin-A and Retin-A Micro (members under the age of 36-Retin-A/Retin-A Micro  ONLY)

A.   A documented:

• Contraindication to one of the following covered alternatives-Avita, benzoyl peroxide (RX)or tretinoin OR,
• Intolerance to one of the following covered alternatives-Avita, benzoyl peroxide (RX) or tretinoin OR,
• Allergy to one of the following covered alternatives-Avita, benzoyl peroxide (RX)or tretinoin OR
• Failure of an adequate trial of one month of one of the following covered alternatives-Avita, benzoyl peroxide (RX) or tretinoin.

 For Retin-A and Retin-A Micro (members equal to or greater than 36 years of age)

A.   A documented diagnosis of acne vulgaris

OR

B.   A documented diagnosis of actinic keratoses

AND

• Lesions are on the face OR
• Lesions are not on the face and therapy includes the use of 5-fluorouracil in conjunction with tretinoin

OR

C.  A documented diagnosis of hypertrophic scars or keloids AND intralesional injection of corticosteroids is ineffective or not tolerated

OR

D.  A documented diagnosis of keratosis follicularis (Darier's disease, Darier-White disease)

OR

E.   A documented diagnosis of facial flat warts

OR

F.   A documented diagnosis of multiple flat warts
 

Note:  Topical tretinoin is not covered for treatment of basal cell carcinoma, lichen planus, or dysplastic nevi because its use in these conditions is not supported by the peer-reviewed medical literature.

AND

G.   A documented:

• Contraindication to one of the following covered alternatives-Avita, benzoyl peroxide (RX)or tretinoin OR,
• Intolerance to one of the following covered alternatives-Avita, benzoyl peroxide (RX) or tretinoin OR,
• Allergy to one of the following covered alternatives-Avita, benzoyl peroxide (RX)or tretinoin OR
• Failure of an adequate trial of one month of one of the following covered alternatives-Avita, benzoyl peroxide (RX) or tretinoin.

For Ziana

A.   A documented:

• Contraindication to two of the following covered alternatives-Avita, benzoyl peroxide (RX), tretinoin or any covered alternative containing clindamycin OR,
• Intolerance to two of the following covered alternatives-Avita, benzoyl peroxide (RX) or tretinoin or any covered product containing clindamycin OR,
• Allergy to two of the following covered alternatives-Avita, benzoyl peroxide (RX)or tretinoin or any covered product containing clindamycin OR
• Failure of an adequate trial of one month each of two of the following covered alternatives-Avita, benzoyl peroxide (RX) or tretinoin or any covered product containing clindamycin