Vtama — Medical Mutual
Atopic dermatitis
Preferred products
- Topical Corticosteroids Groups 1-4
- calcipotriene (cream, foam, ointment, solution) (Dovonex, generic, Sorilux)
- calcitriol ointment (Vectical, generic)
- calcipotriene + betamethasone dipropionate (Taclonex generic, Enstilar, Wynzora)
- pimecrolimus cream (Elidel, generic)
- tacrolimus ointment (Protopic, generic)
Initial criteria
- Prescribed by or in consultation with a physician who specializes in the condition being treated
- Patient is ≥ 18 years of age AND (Patient has tried one Step 1a Product AND one Step 1b product OR Patient has tried one Step 1c Product OR Patient is treating plaque psoriasis affecting face, eyes/eyelids, skin folds, and/or genitalia AND has tried one Step 1b product)
- OR Patient is > 2 years of age AND treating atopic dermatitis AND (Patient has tried one Step 1a Product AND one Step 1d product OR Patient is treating atopic dermatitis affecting face, eyes/eyelids, axilla, or genitalia AND has tried one Step 1d product)
Reauthorization criteria
- Response to therapy is required for continuation of therapy
Approval duration
2 years