Subject: Aklief PA Policy 3362-A 08-2022

Drug

AKLIEF  (trifarotene)

Policy:

FDA-APPROVED INDICATIONS       
Aklief Cream is a retinoid indicated for the topical treatment of acne vulgaris in patients 9 years of age and older. 

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
   •   The requested drug is being prescribed for the topical treatment of acne vulgaris

Place of Service:

Outpatient

The above policy is based on the following references:

1. Aklief cream [package insert]. Dallas, TX: Galderma Laboratories, LP; January 2022.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed July 1, 2022.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed July 1, 2022.
4. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945-73.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

January 01, 2023