tacrolimus ointment 0.03% — Highmark
atopic dermatitis (ICD-10: L20) classified as moderate to severe
Initial criteria
- age ≥ 2 years
- diagnosis of atopic dermatitis (ICD-10: L20) classified as moderate to severe
- member has experienced therapeutic failure, contraindication, or intolerance to at least one topical prescription corticosteroid OR has atopic dermatitis with facial or anogenital involvement
Reauthorization criteria
- member has experienced a positive clinical response to therapy
Approval duration
up to 12 months