Prior Auth Protocol

Prior Authorization Protocol

ONEXTON^TM (clindamycin phosphate and benzoyl peroxide)

NATL

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- For topical treatment of acne vulgaris in patients 12 years of age and older
Health Net Approved Indications and Usage Guidelines:
- Treatment of acne
AND
- Failure or clinically significant adverse effects to generic clindamycin phosphate/benzoyl peroxide topical products
Coverage is Not Authorized For:
- Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
General Information:
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Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
1%/5% clindamycin phosphate/benzoyl peroxide (BenzaClin)	Apply topically to affected area BID (morning and evening)	This field intentionally left blank
1.2%/5% clindamycin phosphate/benzoyl peroxide (Duac, Neuac)	Apply topically to affected area QD in the evening	This field intentionally left blank

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug Dosing Regimen Authorization Limit
Onexton
Apply a pea-sized amount to the face QD
Length of Benefit
Product Availability:

Gel: clindamycin phosphate/benzoyl peroxide 1.2%/3.75% (50 gm pump)
References:

1. Onexton [Prescribing Information]. Bridgewater, NJ: Valeant Pharmaceuticals; November 2014.
2. Clinical Pharmacology Web site. Available at: http://cpip.gsm.com/. Accessed May 31, 2016.
3. Micromedex® Healthcare Series [Internet Database]. Greenwood Village, CO: Thompson Healthcare. Updated periodically. Accessed May 31, 2016.

Drug	Dosing Regimen	Authorization Limit
Onexton	Apply a pea-sized amount to the face QD	Length of Benefit

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.