Covered Uses: | All FDA-approved indications not otherwise excluded from Part D. For topical tretinoin products (examples include Atralin, Avita, Retin-A, Retin-A Micro, and generic topical tretinoin), additional covered uses include: Ichthyosis, Keloids, Lichen planus. |
Exclusion Criteria: | N/A |
Required Medical Information: | N/A |
Age Restrictions: | N/A |
Prescriber Restrictions: | N/A |
Coverage Duration: | Authorization will be for 12 months, unless otherwise noted. |
Other Criteria: | N/A |