Absorica LD™ (Isotretinoin Capsule) Approval Criteria:
- An FDA approved diagnosis of severe recalcitrant nodular acne in non-pregnant patients 12 years of age and older with multiple inflammatory nodules with a diameter of 5mm or greater; AND
- Absorica LD™ is not covered for members older than 20 years of age; AND
- Prescriber must verify member is enrolled in the iPLEDGE REMS program; AND
- Prescriber must verify lipid profile and liver function tests will be monitored prior to initiation of Absorica LD™ and at regular intervals during treatment in accordance with the prescribing information; AND
- A patient-specific, clinically significant reason why the member cannot use other isotretinoin capsules available without prior authorization must be provided; AND
- A recent patient weight must be provided on the prior authorization request in order to authorize the appropriate amount of medication according to drug labeling.