Limited coverage drugs – tacrolimus

Last updated on October 12, 2022

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Generic name / form
tacrolimus ointment

Special Authority 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

Special Authority 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

Patient is intolerant to specified topical corticosteroid treatment

Indefinite

Practitioner exemptions

None

Special notes

Potent corticosteroid medication to be specified
A dermatologist should complete the SA request.

Special Authority requests

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HLTH 5328 - General Special Authority Request (PDF, 656KB)

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Limited coverage drugs – tacrolimus

Practitioner exemptions

Special notes

Special Authority requests