Limited coverage criteria – tacrolimus

Last updated on March 24, 2025

Special Authority requests can now be submitted online. It's simple and quick!

Generic name	tacrolimus
Form	ointment

Special Authority criteria	Approval period
Diagnosis of eczema AND A Special Authority request is submitted by a dermatologist¹ PLUS one of the following: Patient is refractory to three months of specified potent topical corticosteroid therapy² OR Patient is intolerant to specified topical corticosteroid treatment	Indefinite

Special Authority criteria

Approval period

Diagnosis of eczema

AND

A Special Authority request is submitted by a dermatologist¹

PLUS one of the following:

Patient is refractory to three months of specified potent topical corticosteroid therapy²

Patient is intolerant to specified topical corticosteroid treatment

Indefinite

Practitioner exemptions

None

Special notes

¹A dermatologist should complete the SA request
²Potent corticosteroid medication to be specified

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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