Topical Retinoids – Tazarotene and tretinoin Prior Authorization Criteria – Medicare Part D

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:

1. The requested medication will NOT be used for cosmetic purposes
   AND

2. ONE of the following:

   1. The patient has an FDA labeled indication for the requested medication
      OR
   2. The patient has an indication that is supported in CMS approved compendia for the requested medication

Length of Approval: 12 months