Protopic (tacrolimus) 0.1% — CareFirst (Caremark)
Atopic dermatitis (eczema)
Preferred products
- betamethasone dipropionate lotion/spray 0.05%
- betamethasone valerate cream/lotion 0.1%/foam 0.12%
- clocortolone pivalate cream 0.1%
- desonide lotion/ointment 0.05%
- desoximetasone cream 0.05%
- fluocinolone acetonide cream/ointment/kit 0.025%
- flurandrenolide cream/ointment/lotion 0.05%
- fluticasone propionate cream/lotion 0.05%/ointment 0.005%
- hydrocortisone butyrate cream/lipocream/lotion/ointment/solution 0.1%
- hydrocortisone probutate cream 0.1%
- hydrocortisone valerate cream/ointment 0.2%
- mometasone furoate cream/lotion/solution 0.1%
- prednicarbate cream/ointment 0.1%
- triamcinolone acetonide cream/ointment/lotion/kit 0.1% or 0.025% or ointment 0.05%
- amcinonide cream/ointment/lotion 0.1%
- betamethasone dipropionate cream/ointment 0.05%
- betamethasone dipropionate augmented cream/lotion 0.05%
- betamethasone valerate ointment 0.1%
- desoximetasone cream/ointment/spray 0.25%/gel/ointment 0.05%
- diflorasone diacetate cream (emollient base) 0.05%
- halcinonide cream/ointment 0.1%
- fluocinonide cream/emulsified cream/ointment/gel/solution 0.05%
- mometasone furoate ointment 0.1%
- triamcinolone acetonide cream/ointment 0.5%
- triamcinolone acetonide aerosol solution 0.147 mg/g
- betamethasone dipropionate augmented ointment/gel 0.05%
- clobetasol propionate cream/ointment/foam/shampoo/gel/lotion/solution/spray 0.05%/cream 0.025%
- diflorasone diacetate ointment 0.05%
- flurandrenolide tape 4 mcg/cm2
- halobetasol propionate cream/ointment/lotion/kit 0.05%
- fluocinonide cream 0.1%
Initial criteria
- Requested drug is being prescribed for the short-term and non-continuous chronic treatment of moderate to severe atopic dermatitis (eczema)
- For tacrolimus 0.03% ointment, ONE of the following: patient age < 2 years OR drug used on sensitive skin areas (e.g., face, genitals, skin folds) OR patient has inadequate treatment response, intolerance, or contraindication to at least ONE first-line therapy agent (e.g., medium or higher potency topical corticosteroid)
- For tacrolimus 0.1% ointment, patient age ≥ 16 years AND ONE of the following: drug used on sensitive skin areas (e.g., face, genitals, skin folds) OR patient has inadequate treatment response, intolerance, or contraindication to at least ONE first-line therapy agent (e.g., medium or higher potency topical corticosteroid)
Reauthorization criteria
- Requested drug is being prescribed for the short-term and non-continuous chronic treatment of moderate to severe atopic dermatitis (eczema)
- Patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., improvement in or resolution of erythema, edema, xerosis, erosions, excoriations, oozing and crusting, lichenification, or pruritus) AND ONE of the following: request is for tacrolimus 0.03% ointment OR (request is for tacrolimus 0.1% ointment AND patient age ≥ 16 years)
Approval duration
Initial therapy: 3 months; Continuation: 12 months or 36 months depending on reference number 177-F or 1254-F; age <2 years: 3 months