COVERED USES:

FDA Approved Indications:

Elidel® (pimecrolimus) Cream 1% is indicated as second-line therapy for the short- term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non- immunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

Protopic® (tacrolimus) ointment, both 0.03% and 0.1% for adults, and only 0.03% for children aged 2 to 15 years, is indicated as second-line therapy for the short-term and non-continuous chronic treatment of moderate to severe atopic dermatitis in non-immunocompromised adults and children who have failed to respond adequately to other topical prescription treatments for atopic dermatitis, or when those treatments are not advisable.

All FDA approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

Protopic®:

• For the 0.1% strength, must be at least 16 years of age or older
• For the 0.03% strength, must be at least 2 years of age or older

Elidel® 1% (the only strength):

• Must be at least 2 years of age or older

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

1. Documented clinical diagnosis of atopic dermatitis
2. Trial and failure of one prescription topical corticosteroid (example: clobetasol, traiamcinolone)
3. Limited to short term use or intermittent long term therapy

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization for up to one year of intermittent long term therapy.