Summary
Prior authorization is required for isotretinoin products (Absorica, Absorica LD, Accutane, Amnesteem, Claravis and Zenatane) under this BCBSMS policy. Absorica and Absorica LD are currently not covered on any BCBSMS formulary, and the use of samples does not count as current or stable therapy. The most recent update, dated 05/26/2026, added Accutane to the list of drugs, removed an ICD-9 diagnosis code from the code reference, and left the policy statements unchanged.
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What to do
Action · 9 steps
01Get prior authorization before billing isotretinoin products, because prior authorization is required.
02Run a formulary drug search on the patient's member ID to confirm the prescription drug is covered under the benefit plan.
03For the initial evaluation, the individual must be 12 years of age or older, have a documented diagnosis of severe acne with documented failure of at least 60 consecutive days within the past year of an oral antibiotic, one topical retinoid and one topical non-retinoid (or a documented severe acne vulgaris variant such as acne fulminans or acne conglobata), have no contraindications, and have a prescribed dosage within the program quantity limits.
04Initial approval length is a total cumulative dose of 150mg/kg, with a maximum of 6 months.
05A second course requires prior BCBSMS PA approval and documented persistent or recurring severe recalcitrant nodular acne after at least 2 months off isotretinoin, and BCBSMS approves a maximum of two courses (up to 12 total months).
06Prescribers and dispensing pharmacies must be enrolled and activated with iPLEDGE, and patients must be enrolled and meet all iPLEDGE requirements.
07If BCBSMS requests medical records, letters of support alone are not sufficient unless all specific information needed for the medical necessity determination is included.
08Services related to delivery or administration of a medication not approved through the BCBSMS PA review process will be considered not medically necessary.
09New BCBSMS members must obtain pharmacy records confirming medication trials and adherence and submit them on request.
Codes mentioned
L70.3L70.8
Original notice
Isotretinoin Products
bcbsms.com · Always check the source before changing claims.