Prior Authorization Guideline - OptumRx

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Prior Authorization Guideline - OptumRx

Protopic ointment is not indicated for use in children less than 2 years of age.

III.

GUIDELINE

Applies to New Starts Only

A. Elidel 1% will be approved based on all of the following criteria:

1. Patient is ≥ 2 years of age. 1 -AND-

2. History of failure, intolerance, or contraindication to one topical corticosteroid therapy. a

(see Table 2)

Authorization will be issued for 1 year. b

B. Protopic 0.03% will be approved based on all of the following criteria:

1. Patient is ≥ 2 years of age. 2 -AND-

2. History of failure, intolerance, or contraindication to one topical corticosteroid therapy. a

(see Table 2)

-AND-

3. Diagnosis of severe atopic dermatitis. c

Authorization will be issued for 1 year. b

C. Protopic 0.1% will be approved based on all of the following criteria:

1. Patient is ≥18 years of age. 2 -AND-

2. History of failure, intolerance, or contraindication to one topical corticosteroid therapy. a

(see Table 2)

-AND-

3. Diagnosis of severe atopic dermatitis. c

Authorization will be issued for 1 year. b

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