Atopic Dermatitis - Tacrolimus Prior Authorization Criteria – Medicare Part D

Prior Authorization Criteria for Approval

Tacrolimus ointment will be approved when ONE of the following is met: 

1. The patient has a diagnosis of atopic dermatitis AND ONE of the following: 
   1. The patient has tried and had an inadequate response to a topical corticosteroid or topical corticosteroid combination preparation (e.g., hydrocortisone, triamcinolone) OR 
   2. The patient has an intolerance or hypersensitivity to a topical corticosteroid or topical corticosteroid combination preparation OR 
   3. The patient has an FDA labeled contraindication to a topical corticosteroid or topical corticosteroid combination preparation OR 
2. The patient has an indication that is supported in CMS approved compendia for the requested medication

Length of Approval: 12 months