Protopic (tacrolimus) — Point32Health
facial psoriasis
Preferred products
- topical corticosteroids of medium or greater potency covered on formulary
Initial criteria
- Patient has had a trial of at least two (2) Step-1 formulary topical steroid medications of medium or greater potency or one Step-2 medication within the previous 180 days as evidenced by physician documented use, excluding the use of samples OR patient has a physician documented contraindication or intolerance to ALL Step-1 medications
- Patient may have received a non-formulary medication containing the same therapeutic ingredient as evidenced by physician documented use, excluding the use of samples
- For facial or intertriginous psoriasis: patient has diagnosis of mild to moderate atopic dermatitis (eczema) or facial or intertriginous psoriasis AND either (a) patient is not a candidate for medium to high potency corticosteroid therapy (e.g., eyelid dermatitis, facial dermatitis, or dermatitis associated with genital area eruptions) OR (b) patient has a contraindication to topical corticosteroids
Approval duration
12 months