Tretinoin® (generic Vesanoid)

Authorization forms, tretinoin capsules

Traditional & Optimized (05/2020) 

Priority Health Medicaid no longer utilizes drug-specific prior authorization forms. Visit the Medicaid Approved Drug List (ADL) to find the new PA form and drug criteria document.

Go to Medicaid ADL

 Topical tretinoin

Use the Non-covered Medication authorization form