202305-162492
2023
Oscar Insurance Company
EPO
Skin Disorders
Pharmacy/ Prescription Drugs
Formulary Exception
Upheld
Case Summary
Diagnosis: Acne.
Treatment: Formulary exception for Winlevi.
The health plan denied Winlevi.
The denial is upheld.
The patient is a teen-aged male with acne, treated with benzoyl peroxide, Isotretinoin, Winlevi, and Tretinoin. The provider is requesting Winlevi cream. The health plan requires use of at least 3 formulary agents, including adapalene, benzoyl peroxide, clindamycin, erythromycin, Tretinoin and tazarotene.
The formulary agents would also be effective, can possibly be as effective as the requested agent, and would have similar adverse effects such as dryness and irritation.
The patient has tried benzoyl peroxide and Tretinoin, but has not tried clindamycin and erythromycin. These would also be appropriate and effective therapies.