Effective July 5, 2016

UNIVERSITY OF MICHIGAN – PROTOPIC (tacrolimus)

Some of the information needed to make a determination for coverage is not specifically requested on

the Michigan Prior Authorization Request Form for Prescription Drugs. To avoid delays in reviewing your

request, please make sure to include all of the following information.

You must also answer ALL questions related to your patient's condition 1. Is the patient 2 years of age or older? Y N

2. Does the patient have a diagnosis of chronic cutaneous GVHD, refractory to systemic corticosteroid therapy? If yes, stop here, otherwise continue

Y N

3. Does the patient have a diagnosis of moderate to severe atopic dermatitis (eczema)? Y N

4. Has the patient had a trial and failure of at least two topical corticosteroids of medium to high potency or does the patient have a contraindication or allergy to all corticosteroids (not the vehicles)?

Y N

5. Will therapy be discontinued after signs and symptoms of the disease resolve? Y N

6. Will the patient be advised to limit or avoid their exposure to natural or artificial sunlight, sun lamps, tanning beds, and treatment with UVA or UVB light and not utilize occlusive dressings?

Y N

7. Will female patients be advised to notify their physician if they become pregnant or are breastfeeding? Y N