WHA

Topical Immunomodulators

Indications for Prior Authorization

Elidel (pimecrolimus)
  • For diagnosis of Mild to Moderate Atopic Dermatitis
    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)
  • For diagnosis of Moderate to Severe Atopic Dermatitis
    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.

Criteria

Brand Elidel cream, generic pimecrolimus cream, Brand Protopic ointment

Step Therapy

Length of Approval: 12 Month(s)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure (of a minimum 30-day supply), contraindication or intolerance of generic tacrolimus ointment

  • Guideline ID
    GL-154183

  • Formulary
    EHB

  • Effective date
    Nov 1, 2024

  • P&T approval date
    Jun 19, 2019

P & T Revisions

2024-09-02, 2023-08-02, 2022-06-16, 2021-10-12, 2021-05-05, 2020-08-05, 2020-05-14

  1. Elidel Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. September 2020.
  2. Protopic Prescribing Information. LEO Pharma Inc. Madison, NJ. June 2022.
  3. Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023 Jul;89(1):e1-e20. doi: 10.1016/j.jaad.2022.12.029. Epub 2023 Jan 12. PMID: 36641009.
  • 2024-09-02: 2024 Annual Review. No criteria changes. Updated references.
  • 2023-08-02: Annual review, no changes to criteria
  • 2022-06-16: Annual Review. Added FDA approved diagnosis requirement to criteria.
  • 2021-10-12: Add EHB formulary to the guideline.
  • 2021-05-05: Annual Review
  • 2020-08-05: Program Update
  • 2020-05-14: Annual Review

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