pimecrolimus — CareFirst (Caremark)
Vitiligo on the head or neck
Preferred products
- betamethasone dipropionate
- betamethasone valerate
- clocortolone pivalate
- desonide
- desoximetasone
- fluocinolone acetonide
- flurandrenolide
- fluticasone propionate
- hydrocortisone butyrate
- hydrocortisone probutate
- hydrocortisone valerate
- mometasone furoate
- prednicarbate
- triamcinolone acetonide
- amcinonide
- diflorasone diacetate
- halcinonide
- fluocinonide
- halobetasol propionate
- clobetasol propionate
Initial criteria
- For atopic dermatitis (eczema): Authorization may be granted when the drug is being prescribed for the short-term and noncontinuous chronic treatment of mild to moderate atopic dermatitis when ONE of the following criteria is met: (a) patient age < 2 years; OR (b) drug will be used on sensitive skin areas (e.g., face, genitals, skin folds); OR (c) patient has experienced an inadequate treatment response, intolerance, or contraindication to at least ONE first-line therapy agent (e.g., medium or higher potency topical corticosteroid).
- For psoriasis: Authorization may be granted when prescribed for psoriasis on the face, genitals, or skin folds.
- For vitiligo: Authorization may be granted when prescribed for vitiligo on the head or neck.
Reauthorization criteria
- Atopic dermatitis: patient has achieved or maintained a positive clinical response as evidenced by improvement or resolution of signs and symptoms (e.g., erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus).
- Psoriasis: patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., clear or almost clear outcome, patient satisfaction).
- Vitiligo: patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., meaningful repigmentation).
Approval duration
Initial: 3 months (patients age ≥ 2 years or < 2 years); Continuation: 36 months (age ≥ 2 years); 3 months (age < 2 years)