tacrolimus ointment — CareFirst (Caremark)

Initial criteria

• Requested drug is being prescribed for vitiligo on the head or neck
• For tacrolimus 0.03% ointment OR tacrolimus 0.1% ointment when patient age ≥ 16 years

Reauthorization criteria

• Patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., meaningful repigmentation) AND request is for tacrolimus 0.03% ointment OR (tacrolimus 0.1% ointment and patient age ≥ 16 years)

Approval duration

Initial therapy: 3 months; Continuation: 12–36 months depending on reference number; age <2 years: 3 months