Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

tacrolimus ointment

Criteria

Approval Period

Diagnosis of eczema

PLUS

Medication prescribed by a dermatologist

PLUS one of the following:

  • Patient is refractory to three months of specified potent topical corticosteroid therapy

OR

  • Patient is intolerant to specified topical corticosteroid treatment.
Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Potent corticosteroid medication to be specified

Special Authority Request Form(s)

A dermatologist should complete the request form below.
Special Authority Request Form (PDF, 523KB)