Tacrolimus 0.03% and 0.1% ointment (generic) — Medical Mutual

Preferred products

• Prescription topical corticosteroids (brand or generic)

Initial criteria

• If the patient has tried a preferred medication, then authorization for a non-preferred (step 2) medication may be given
• If the patient has tried a preferred medication AND generic tacrolimus ointment, then authorization may be given for brand Protopic ointment
• If the patient has tried a preferred medication AND generic pimecrolimus cream, then authorization may be given for brand Elidel cream
• If the patient has tried a preferred medication AND a non-preferred (step 2) medication, then authorization may be given for Eucrisa ointment
• Authorization may be given for a generic, non-preferred medication if the patient has a dermatologic condition affecting the face, eyes/eyelids, axilla, genitalia, and/or other skin folds
• Authorization may be given for Eucrisa if the patient is between the age of 3 months and 1 year old OR if the patient is between the ages of 1 and 2 years old and has tried a preferred product

Reauthorization criteria

• Patient has been stable and continuing therapy with the requested non-preferred agent for at least 90 days, verified by prescription claims history or prescriber verification, AND there is no generic equivalent available for the requested product

Approval duration

initial 2 years; reauth 2 years; continuation 1 year