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State Health Plan
Topical tretinoin (Retin-A®, others) and tazarotene (Tazorac®) Prior Authorization Program

As of October 3, 2011, topical tretinoin products, tretinoin combination products and tazarotene (Tazorac) will require prior authorization for members aged 30 years and older. Patients under 30 will not require a review.

According to Plan benefits, prescription drugs are not covered for cosmetic purposes. Therefore, the prior authorization requirement will ensure that the utilization of tretinoin and tazarotene is for non-cosmetic purposes. Examples of uses that are considered cosmetic include (but are not limited to) photo-aging, wrinkling, hyperpigmentation, sun damage and melasma.

In addition for tazarotene, if the non-cosmetic use is for the treatment of acne, the member must first have experienced treatment failure or intolerance to a topical form of generic tretinoin.

Providers may call Medco toll-free at 1-800-417-1764 from 8 a.m. to 9 p.m., Eastern Time, Monday through Friday, to request a review. If the medication is not approved during the coverage review, the member will be responsible for the full cost of his or her prescription.

Please visit the Plan website at www.shpnc.org for further information.