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PAxx Solodyn/ tetracycline/ doxycycline PAxx Orecea

U.S. Doctors Resources, L.L.C.



Solodyn® (minocycline ER)_______Dynacin® (minocycline)
Orecea® (doxycycline) _______Actilate® (tetracycline)
_______Minocin® (micocycline)_______ Vibramycin® (doxycycline monohydrate)




The Prior Authorization for this medication has been denied. Further review is pending as:
Minocycline 100mg is Provided Free of Deductible.

1. There is no superiority of any individual tetracycline preparation for Acne[1], therefore, minocycline or generic tetracycline[2] are approved by the Benefit Manager. Record symptoms initially and at 3-months in non-critical patients.

2. Refer to the Benefit Manager’s designated physician or his designee for
_____ a. Alternative Pricing if available
_____ b. Second Opinion alternative treatments for acne[2] starting with Pro-Active(TM) and over-the-counter preparations.

Pending (1.) and (2.), the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:

ATTN: Benefit Manager
City of Hazel Park Self-Insurance Health Program
111 East Nine Mile Road
Hazel Park, Michigan 48030

Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account in the boxes below.


Demographics Health Insurance/ Credit Card
Member Name:____________________________________ Member Name on the Card:_____________________________________
Insurance ID:____________________________________ Issuing Service: VISA, MC, Discover _________________
Date of Birth:____________________________________ Number:____________________________________
Street Address:____________________________________ Expiration:____________________________________
City/ State/ Zip code:____________________________________CVV Code:____________________________________
Telephone Number:____________________________________
Signature of Employee/ Insured:

Signature of Treating Physician:___________________________________

1. Physician Desk Reference

2. Cochrane Database Syst Rev. 2003;(1):CD002086. Minocycline for acne vulgaris: efficacy and safety. Garner SE1, Eady EA, Popescu C, Newton J, Li WA.

Signed b.n.r. Benefit Manager ___________________________________ date:__________

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