Acne

From UofL General Peds

Acne Formulary for Passport for patients 18yo and under

Drug Name Formulary Status

ADAPALENE

Adapalene Cream 0.1%

Non-formulary

Adapalene Gel 0.1%

OTC covered, RX version requires PA

Adapalene Gel 0.3%

Non-formulary

Adapalene Lotion 0.1%

Non-formulary

AZELAIC ACID

Azelaic Acid Cream, Foam

Non-formulary

BENZOYL PEROXIDE

Benzoyl Peroxide Liq- 4%, 5% , 10%

Formulary

Benzoyl Peroxide Cream-10%

Formulary

Benzoyl Peroxide Gel-2.5%, 5%, 10%

Formulary

Benzoyl Peroxide Foam-5.3%, 5.5%, 9.5%, 9.8%

Non-formulary

Benzoyl Peroxide Liquid-5.25%, 7%

Non-Formulary

Benzoyl Peroxide Gel-2.75%, 5.25%

Non-formulary

Benzoyl Peroxide Cloth 6%

Non-formulary

CLINDAMYCIN

Clindamycin Phos Soln 1%

Formulary

Clindamycin Phos Swab, 1%

Formulary

Clindamycin Phos Gel-1%, Lotion-1%

Formulary, Requires PA

Clindamycin Phos Foam-1%

Non-formulary

DAPSONE

Dapsone Gel 5%

Non-formulary

ERYTHROMYCIN

Erythromycin Soln-2%

Formulary

Erythromycin Gel, Pads-2%

Non-formulary

SULFACETAMIDE SODIUM, SULFACETAMIDE W/SULFUR PRODUCTS, BRIMONIDINE PRODUCTS

All products

Non-formulary

TAZAROTENE

Tazarotene Cream-0.05%, 0.1 %

Formulary, Requires PA

Tazarotene Gel-0.05%, 0.1%, Foam-0.1%

Non-formulary

TRETINOIN

Tretinoin Cream-0.025%, 0.05%, 0.1%

Generic requires PA, Brand-Non-formulary

Tretinoin Gel-0.1%, 0.025%

Generic requires PA, Brand-Non-formulary

Tretinoin Gel-0.05%

Non-formulary

Tretinoin Microsphere Gel-0.04%, 0.1%

Non-formulary

COMBO AGENTS

Adapalene/Benzoyl Peroxide Gel-0.1/2.5%, 0.3/2.5%

Non-formulary

Benzoyl Peroxide/Erythromycin Gel-5/3%

Generic requires PA, Brand-Non-formulary

Clindamycin Phos/Benzoyl Peroxide (Refrig) Gel-1.2-5.0%

Formulary, Requires PA

Clindamycin Phos/Benzoyl Peroxide Gel-1.2-2.5%, 1.2-3.75%, 1-5%

Non-formulary

Clindamycin Phos/Tretinoin Gel-1.2-0.025%

Non-formulary

ORAL AGENTS - ISOTRETINOIN CAPS

Isotretinoin Caps-10mg, 20mg, 30mg, 40mg Amnesteem Claravis Isotretinoin Myorisan Zenatane

Formulary, Requires PA

Absorica Caps-10mg, 20mg, 25mg, 30mg, 35mg, 40mg

Non-formulary

  • All acne agents for 19yo and older are non-formulary
  • Updated 3/2019