WHA
 

Topical Immunomodulators

Indications for Prior Authorization

Pimecrolimus cream
  • For diagnosis of Atopic Dermatitis (AD)
    Indicated as second-line therapy for the short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

Eucrisa (crisaborole) ointment
  • For diagnosis of Atopic Dermatitis (AD)
    Indicated for topical treatment of mild to moderate atopic dermatitis in adult and pediatric patients 3 months of age and older.

Opzelura (ruxolitinib) cream
  • For diagnosis of Atopic Dermatitis (AD)
    Indicated for the topical short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adult and pediatric patients 2 years of age and older whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Limitation of Use: Use of Opzelura in combination with therapeutic biologics, other JAK inhibitors or potent immunosuppressants such as azathioprine or cyclosporine is not recommended.

  • For diagnosis of Nonsegmental Vitiligo
    Indicated for the topical treatment of nonsegmental vitiligo in adult and pediatric patients 12 years of age and older. Limitation of Use: Use of Opzelura in combination with therapeutic biologics, other JAK inhibitors, or potent immunosuppressants such as azathioprine or cyclosporine is not recommended.

Vtama (tapinarof) cream
  • For diagnosis of Atopic Dermatitis (AD)
    Indicated for the topical treatment of atopic dermatitis in adults and pediatric patients 2 years of age and older.

  • For diagnosis of Plaque Psoriasis (PsO)
    Indicated for the topical treatment of plaque psoriasis in adults.

Criteria

Generic pimecrolimus cream

Step Therapy

Length of Approval: 12 Month(s)
For diagnosis of Atopic Dermatitis (AD)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure of a minimum 30-day supply, contraindication, or intolerance of generic tacrolimus ointment
Eucrisa

Step Therapy

Length of Approval: 12 Month(s)
For diagnosis of Atopic Dermatitis (AD)

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to ONE of the following [5]:
    • Medium or higher potency topical corticosteroid
    • Generic topical calcineurin inhibitor (e.g., tacrolimus ointment)
Opzelura

Step Therapy

Length of Approval: 12 Month(s)
For diagnosis of AD, Nonsegmental Vitiligo

  • One of the following:
    • Both of the following:
      • Diagnosis of mild to moderate atopic dermatitis
        • AND
      • Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to ONE of the following [5]:
        • Medium or higher potency topical corticosteroid
        • Generic topical calcineurin inhibitor (e.g., tacrolimus ointment)
      OR
    • Both of the following:
      • Diagnosis of nonsegmental vitiligo
        • AND
      • Trial and failure of a minimum 30-day supply, contraindication, or intolerance to ONE of the following [6]:
        • Medium or higher potency topical corticosteroid
        • Tacrolimus ointment
Vtama

Step Therapy

Length of Approval: 12 Month(s)
For diagnosis of AD, Plaque Psoriasis (PsO)

  • One of the following:
    • Both of the following:
      • Diagnosis of atopic dermatitis
        • AND
      • Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to ONE of the following [5]:
        • Medium or higher potency topical corticosteroid
        • Generic topical calcineurin inhibitor (e.g., tacrolimus ointment)
      OR
    • Both of the following:
      • Diagnosis of plaque psoriasis
        • AND
      • Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to ONE of the following generic topical therapies [7]:
        • Corticosteroids (e.g., betamethasone, clobetasol)
        • Vitamin D analogs (e.g., calcitriol, calcipotriene)
        • Tazarotene
        • Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus)
        • Combination topical therapy (e.g., vitamin D analog/corticosteroid)

  • Guideline ID
    GL-521255

  • Formulary
    ehb

  • Effective date
    Apr 1, 2026

  • P&T approval date
    Jun 19, 2019

P & T Revisions

2026-03-06, 2025-12-18, 2025-12-18, 2025-10-02, 2024-09-02, 2023-08-02, 2022-06-16, 2021-10-12, 2021-05-05, 2020-08-05, 2020-05-14

  1. Elidel Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. September 2020.
  2. Eucrisa Prescribing Information. Pfizer, Inc. New York, NY. April 2023.
  3. Opzelura Prescribing Information. Incyte Corp. Wilmington, DE. September 2025.
  4. Vtama Prescribing Information. Dermavant Sciences Inc. Long Beach, CA. May 2022.
  5. Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023 Jul;89(1):e1-e20. doi: 10.1016/j.jaad.2022.12.029. Epub 2023 Jan 12. PMID: 36641009.
  6. Taieb A, Alomar A, Bohm M, et al. Guidelines for the management of vitiligo: the European Dermatology Forum consensus. Br J Dermatol. 2013;168(1):5-19.
  7. Elmets CA, Korman NJ, Farley Prater E, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol 2021;84:432-70.
  • 2026-03-06: Combined guidelines for Pimecrolimus cream, Eucrisa, Opzelura, and Vtama. Removed brand Elidel as it is discontinued.
  • 2025-12-18: No criteria change, bulk copy oRX-EHB
  • 2025-12-18: no criteria changes, added IL statute operational note
  • 2025-10-02: 2025 Annual Review. Removed Protopic as a target to guideline as product is obsolete.
  • 2024-09-02: 2024 Annual Review. No criteria changes. Updated references.
  • 2023-08-02: Annual review, no changes to criteria
  • 2022-06-16: Annual Review. Added FDA approved diagnosis requirement to criteria.
  • 2021-10-12: Add EHB formulary to the guideline.
  • 2021-05-05: Annual Review
  • 2020-08-05: Program Update
  • 2020-05-14: Annual Review