Prior Authorization Topical Immunomodulators Elidel and Protopic 0.03%

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Bethanie Spencer
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Drugs Requiring Label Name GCN ELIDEL 1% CREAM 15348 PROTOPIC 0.03% OINTMENT 12289 TACROLIMUS 0.03% OINTMENT 12289 Clinical Edit Criteria Logic 1.

1 Drugs Requiring Label Name GCN ELIDEL 1% CREAM PROTOPIC 0.03% OINTMENT TACROLIMUS 0.03% OINTMENT Clinical Edit Criteria Logic 1. Does the client have a diagnosis of localized skin graft versus host disease in the last 365 days? (Go to #2) (Go to #3) 2. Has the client had a bone marrow transplant in the last 365 days? (Approve 365 days) (Go to #3) 3. Is the client less than or equal to 2 years of age? (Go to #4) (Go to #5) 4. Does the client have a history of a topical steroid or nystatin / triamcinolone prescription in the last 730 days? (Go to #5) () 5. Does the client have a diagnosis of Atopic Dermatitis (eczema) in the last 730 days? (Go to #6) () 6. Does the client have a history of a topical steroid or nystatin / triamcinolone prescription in the last 730 days? (Go to #8) (Go to #7) 7. Does the client have a history of a prior pimecrolimus (ELIDEL) / tacrolimus (PROTOPIC) prescription in the last 365 days? (Go to #8) () 8. Does the client have a diagnosis of HIV or Immune System Disorder in the last 730 days? () (Go to #9) 9. Does the client have a history of HIV drugs or immunosuppressants in the last 730 days? () (Go to #10) 10. Does the client have a history of antineoplastic agents in the last 730 days? () (Go to #11) 11. Does the client have a history of a skin absorption disorder or a skin malignancy in the last 730 days? () (Go to #12)

2 12. Does the client have a history of a prior pimecrolimus (ELIDEL) / tacrolimus (PROTOPIC) prescription less than or equal to 180 days in the last 200 days? (Approve 180 days) ()

3 Clinical Edit Criteria Logic Step 1: Does the client have a diagnosis of localized skin graft versus host disease in the last 365 days? Step 2: Has the client had a bone marrow transplant in the last 365 days? Approve for 365 days Step 3: Is the client less than or equal to 2 years of age? Step 4: Does the client have a history of a topical steroid or nystatin/ triamcinolone prescription in the last 730 days? Step 5: Does the client have a diagnosis of Atopic Dermatitis (eczema) in the last 730 days? Step 6: Does the client have a history of a topical steroid or nystatin/triamcinolone prescription in the last 730 days? Step 7: Does the client have a history of a prior pimecrolimus (ELIDEL)/ tacrolimus (PROTOPIC) prescription in the last 365 days? Step 8: Does the client have a diagnosis of HIV or Immune System Disorder in the last 730 days? Step 9: Does the client have a history of HIV drugs or immunosuppressants in the last 730 days? Step 10: Does the client have a history of antineoplastic agents in the last 730 days? Step 11: Does the client have a history of a skin absorption disorder or a skin malignancy in the last 730 days? Step 12: Does the client have a histroy of a prior pimecrolimus (ELIDEL)/tacrolimus (PROTOPIC) prescritpion less than or equal to 180 days in the last 200 days? Clinical Edit Criteria Supporting Tables Approve for 180 days

4 ICD-10 Code Description D89.81 GRAFT-VERSUS-HOST DISEASE Step 1 (diagnosis of graft-versus-host disease) Required diagnosis: 1 Look back timeframe: 365 Days CPT Code Description ALLOGENEIC INFUSION AUTOLOGOUS TRANSPLANT Step 2 (history of bone marrow transplant) Required code: 1 Look back timeframe: 365 Days ALLOGENEIC DONOR LYMPHOCYTE INFUSION ALLOGENEIC HEMATOPOIETIC CELLULAR TRANSPLANT BOOST Label Name Step 4 (history or topical steroid or nystatin/triamcinolone prescription) Required quantity: 1 Look back timeframe: 730 Days GCN ALCLOMETASONE DIPRO 0.05% CRM ALCLOMETASONE DIPR 0.05% OINT AMCINONIDE 0.1% CREAM AMCINONIDE 0.1% LOTION AMCINONIDE 0.1% OINTMENT ANUSOL-HC 2.5% CREAM APEXICON 0.05% OINTMENT APEXICON E 0.05% CREAM BETAMETHASONE DP 0.05% CRM BETAMETHASONE DP 0.05% LOT BETAMETHASONE DP 0.05% OINT BETAMETHASONE DP AUG 0.05% CRM BETAMETHASONE DP AUG 0.05% GEL BETAMETHASONE DP AUG 0.05% LOT BETAMETHASONE DP AUG 0.05% OIN BETAMETHASONE VA 0.1% CREAM BETAMETHASONE VA 0.1% LOTION BETAMETHASONE VALER 0.1% OINTM 31110

5 BETA-VAL 0.1% LOTION CLOBETASOL 0.05% CREAM CLOBETASOL 0.05% GEL CLOBETASOL 0.05% OINTMENT CLOBETASOL 0.05% SOLUTION CLOBETASOL EMOLLIENT 0.05% CRM CLOBETASOL PROP 0.05% FOAM CLOBEX 0.05% SPRAY CLOBEX 0.05% TOPICAL LOTION CLODERM 0.1% CREAM CORDRAN 4 MCG/SQ CM TAPE CORMAX 0.05% SOLUTION CORTISPORIN OINTMENT CUTIVATE 0.05% LOTION DERMA-SMOOTHE-FS BODY OIL DERMA-SMOOTHE-FS SCALP OIL DERMATOP 0.1% CREAM DERMATOP 0.1% OINTMENT DESONIDE 0.05% CREAM DESONIDE 0.05% LOTION DESONIDE 0.05% OINTMENT DESOXIMETASONE 0.05% CREAM DESOXIMETASONE 0.25% CREAM DESOXIMETASONE 0.05% GEL 6120 DESOXIMETASONE 0.25% OINTMENT DIFLORASONE 0.05% CREAM DIFLORASONE 0.05% OINTMENT DIPROLENE 0.05% LOTION DIPROLENE 0.05% OINTMENT DIPROLENE AF 0.05% CREAM ELOCON 0.1% CREAM ELOCON 0.1% LOTION 6034 ELOCON 0.1% OINTMENT FLUOCINOLONE 0.01% CREAM FLUOCINOLONE 0.025% CREAM FLUOCINONIDE 0.05% CREAM FLUOCINONIDE 0.05% GEL 31380

6 FLUOCINOLONE 0.025% OINT FLUOCINONIDE 0.05% OINTMENT FLUOCINOLONE 0.01% SOLUTION FLUOCINONIDE 0.05% SOLUTION FLUOCINONIDE-E 0.05% CREAM FLUOCINONIDE-EMOL 0.05% CREAM FLUTICASONE PROP 0.05% CREAM FLUTICASONE PROP 0.005% OINT HALOBETASOL PROP 0.05% CREAM HALOBETASOL PROP 0.05% OINTMNT HALOG 0.1% CREAM HALOG 0.1% OINTMENT HYDRO SKIN 1% LOTION HYDROCORTISONE 0.5% CREAM HYDROCORTISONE 1% CREAM HYDROCORTISONE 1% CREAM HYDROCORTISONE 2.5% CREAM HYDROCORTISONE 1% LOTION HYDROCORTISONE 2.5% LOTION HYDROCORTISONE 0.5% OINTMENT HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 2.5% OINTMENT HYDROCORTISONE 0.1% SOLN HYDROCORTISONE ACETATE 2% GEL HYDROCORTISONE BUTY 0.1% CREAM HYDROCORTISONE BUTYR 0.1% OINT HYDROCORTISONE VAL 0.2% CREAM HYDROCORTISONE VAL 0.2% OINTMT 6040 ITCH-X HC 1% LOTION LOKARA 0.05% LOTION MEDI-CORTISONE 1% CREAM MOMETASONE FUROATE 0.1% CREAM MOMETASONE FUROATE 0.1% OINT MOMETASONE FUROATE 0.1% SOLN 6034 NUZON GEL OLUX 0.05% FOAM 89743

7 OLUX-E 0.05% FOAM PREDNICARBATE 0.1% CREAM PREDNICARBATE 0.1% OINTMENT PROCTOCREAM-HC 2.5% CREAM PROCTOSOL-HC 2.5% CREAM PROCTOZONE-HC 2.5% CREAM TOPICORT 0.05% GEL 6120 TOPICORT 0.25% CREAM TOPICORT 0.25% OINTMENT TOPICORT LP 0.05% CREAM TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE 0.5% CREAM TRIAMCINOLONE 0.025% LOTION TRIAMCINOLONE 0.1% LOTION TRIAMCINOLONE 0.025% OINT TRIAMCINOLONE 0.1% OINTMENT TRIAMCINOLONE 0.5% OINTMENT TRIANEX 0.05% OINTMENT ULTRAVATE 0.05% CREAM VANOS 0.1% CREAM VERDESO 0.05% FOAM WESTCORT 0.2% OINTMENT 6040 ICD-9 Code Description Step 5 (diagnosis of atopic dermatitis) Required diagnosis: 1 Look back timeframe: 730 Days 691 ATOPIC DERMATITIS AND RELATED CONDITIONS 6918 OTHER ATOPIC DERMATITIS ICD-10 Code L200 L2081 L2082 L2084 Description BESNIER'S PRURIGO ATOPIC NEURODERMATITIS FLEXURAL ECZEMA INTRINSIC (ALLERGIC) ECZEMA

8 L2089 L209 OTHER ATOPIC DERMATITIS ATOPIC DERMATITIS, UNSPECIFIED Step 6 (history or topical steroid or nystatin/triamcinolone prescription) Required diagnosis: 1 Look back timeframe: 730 Days For the list of topical steroids and nystatin/triamcinolone drugs that pertain to this step, see the Topical Steroids and Nystatin/Triamcinolone Drugs table in Step 4. Label Name Step 7 (history of a prior pimecrolimus/tacrolimus prescription) Required quantity: 1 Look back timeframe: 365 Days GCN ELIDEL 1% CREAM PROTOPIC 0.03% OINTMENT PROTOPIC 0.1% OINTMENT TACROLIMUS 0.03% OINTMENT TACROLIMUS 0.1% OINTMENT ICD-9 Code Description 042 HUMAN IMMUNO VIRUS DIS Step 8 (diagnosis of HIV or immune system disorder) Required quantity: 1 Look back timeframe: 730 Days 279 DISORDERS INVOLVING THE IMMUNE MECHANISM 2790 DEFICIENCY OF HUMORAL IMMUNITY HYPOGAMMAGLOBULINEM NOS SELECTIVE IGA IMMUNODEF SELECTIVE IGM IMMUNODEF SELECTIVE IG DEFIC NEC CONG HYPOGAMMAGLOBULINEM IMMUNODEFIC W HYPER-IGM COMMON VARIABL IMMUNODEF HUMORAL IMMUNITY DEF NEC 2791 DEFICIENCY OF CELL-MEDIATED IMMUNITY IMMUNDEF T-CELL DEF NOS

9 27911 DIGEORGE'S SYNDROME WISKOTT-ALDRICH SYNDROME NEZELOF'S SYNDROME DEFIC CELL IMMUNITY NOS 2792 COMBINED IMMUNITY DEFIC 2793 IMMUNITY DEFICIENCY NOS 2794 AUTOIMMUNE DISEASE NEC 2795 GRAFT-VERSUS-HOST DISEASE GRAFT-VERSUS-HOST DISEASE, UNSPECIFIED ACUTE GRAFT-VERSUS-HOST DISEASE CHRONIC GRAFT-VERSUS-HOST DISEASE ACUTE ON CHRONIC GRAFT-VERSUS-HOST DISEASE 2798 IMMUNE MECHANISM DIS NEC 2799 IMMUNE MECHANISM DIS NOS ICD-10 Code B20 D800 D801 D802 D803 D804 D805 D806 D807 D808 D809 D810 D811 D812 Description HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE HEREDITARY HYPOGAMMAGLOBULINEMIA NONFAMILIAL HYPOGAMMAGLOBULINEMIA SELECTIVE DEFICIENCY OF IMMUNOGLOBULIN A [IGA] SELECTIVE DEFICIENCY OF IMMUNOGLOBULIN G [IGG] SUBCLASSES SELECTIVE DEFICIENCY OF IMMUNOGLOBULIN M [IGM] IMMUNODEFICIENCY WITH INCREASED IMMUNOGLOBULIN M [IGM] ANTIBODY DEFICIENCY WITH NEAR-NORMAL IMMUNOGLOBULINS OR WITH HYPERIMMUNOGLOBULINEMIA TRANSIENT HYPOGAMMAGLOBULINEMIA OF INFANCY OTHER IMMUNODEFICIENCIES WITH PREDOMINANTLY ANTIBODY DEFECTS IMMUNODEFICIENCY WITH PREDOMINANTLY ANTIBODY DEFECTS, UNSPECIFIED SEVERE COMBINED IMMUNODEFICIENCY [SCID] WITH RETICULAR DYSGENESIS SEVERE COMBINED IMMUNODEFICIENCY [SCID] WITH LOW T- AND B-CELL NUMBERS SEVERE COMBINED IMMUNODEFICIENCY [SCID] WITH LOW OR NORMAL B-CELL NUMBERS

10 D814 D816 D817 D8189 D819 D820 D821 D822 D823 D824 D828 D829 D830 D831 D832 D838 D839 D840 D841 D848 D849 D893 D89810 D89811 D89812 D89813 D8989 D899 NEZELOF'S SYNDROME MAJOR HISTOCOMPATIBILITY COMPLEX CLASS I DEFICIENCY MAJOR HISTOCOMPATIBILITY COMPLEX CLASS II DEFICIENCY OTHER COMBINED IMMUNODEFICIENCIES COMBINED IMMUNODEFICIENCY, UNSPECIFIED WISKOTT-ALDRICH SYNDROME DI GEORGE'S SYNDROME IMMUNODEFICIENCY WITH SHORT-LIMBED STATURE IMMUNODEFICIENCY FOLLOWING HEREDITARY DEFECTIVE RESPONSE TO EPSTEIN-BARR VIRUS HYPERIMMUNOGLOBULIN E [IGE] SYNDROME IMMUNODEFICIENCY ASSOCIATED WITH OTHER SPECIFIED MAJOR DEFECTS IMMUNODEFICIENCY ASSOCIATED WITH MAJOR DEFECT, UNSPECIFIED COMMON VARIABLE IMMUNODEFICIENCY WITH PREDOMINANT ABNORMALITIES OF B-CELL NUMBERS AND FUNCTION COMMON VARIABLE IMMUNODEFICIENCY WITH PREDOMINANT IMMUNOREGULATORY T-CELL DISORDERS COMMON VARIABLE IMMUNODEFICIENCY WITH AUTOANTIBODIES TO B-OR T-CELLS OTHER COMMON VARIABLE IMMUNODEFICIENCIES COMMON VARIABLE IMMUNODEFICIENCY, UNSPECIFIED LYMPHOCYTE FUNCTION ANTIGEN-1 [LFA-1] DEFECT DEFECTS IN THE COMPLEMENT SYSTEM OTHER SPECIFIED IMMUNODEFICIENCIES IMMUNODEFICIENCY, UNSPECIFIED IMMUNE RECONSTITUTION SYNDROME ACUTE GRAFT-VERSUS-HOST DISEASE CHRONIC GRAFT-VERSUS-HOST DISEASE ACUTE ON CHRONIC GRAFT-VERSUS-HOST DISEASE GRAFT-VERSUS-HOST DISEASE, UNSPECIFIED OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM, NOT ELSEWHERE CLASSIFIED DISORDER INVOLVING THE IMMUNE MECHANISM, UNSPECIFIED

11 Label Name Step 9 (history of HIV drugs or immunosuppressants) Required quantity: 1 Look back timeframe: 730 Days GCN ABACAVIR 300 MG TABLET ABACAVIR-LAMIVUDINE-ZIDOV TAB AFINITOR 10 MG TABLET AFINITOR 2.5 MG TABLET AFINITOR 5 MG TABLET AFINITOR 7.5 MG TABLET AFINITOR DISPERZ 2 MG TABLET AFINITOR DISPERZ 3 MG TABLET AFINITOR DISPERZ 5 MG TABLET APTIVUS 250 MG CAPSULE ASTAGRAF XL 0.5 MG CAPSULE ASTAGRAF XL 1 MG CAPSULE ASTAGRAF XL 5 MG CAPSULE ATRIPLA TABLET AZATHIOPRINE 50 MG TABLET CELLCEPT 200 MG/ML ORAL SUSP CELLCEPT 250 MG CAPSULE CELLCEPT 500 MG TABLET COMBIVIR TABLET COMPLERA TABLET CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE 50 MG SOFTGEL CYCLOSPORINE MODIFIED 100 MG CYCLOSPORINE MODIFIED 25 MG DIDANOSINE DR 125 MG CAPSULE DIDANOSINE DR 200 MG CAPSULE DIDANOSINE DR 250 MG CAPSULE DIDANOSINE DR 400 MG CAPSULE EDURANT 25 MG TABLET EMTRIVA 200 MG CAPSULE 20019

12 ENVARSUS XR 0.75 MG TABLET ENVARSUS XR 1 MG TABLET ENVARSUS XR 4 MG TABLET EPIVIR 10 MG/ML ORAL SOLN EPIVIR 150 MG TABLET EPIVIR 300 MG TABLET EPZICOM TABLET EVOTAZ MG TABLET FUZEON 90 MG VIAL GENGRAF 100 MG CAPSULE GENGRAF 100 MG/ML SOLUTION GENGRAF 25 MG CAPSULE GENVOYA TABLET IMURAN 50 MG TABLET INTELENCE 100 MG TABLET INTELENCE 200 MG TABLET INTELENCE 25 MG TABLET INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET ISENTRESS 100 MG POWDER PACKET ISENTRESS 100 MG TABLET CHEW ISENTRESS 25 MG TABLET CHEW ISENTRESS 400 MG TABLET KALETRA MG TABLET KALETRA MG TABLET KALETRA /5 ML ORAL SOLU LAMIVUDINE 100 MG TABLET LAMIVUDINE 10MG/ML ORAL SOLUTION LAMIVUDINE 150 MG TABLET LAMIVUDINE 300 MG TABLET LAMIVUDINE-ZIDOVUDINE TABLET LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET MYCOPHENOLATE 250 MG CAPSULE MYCOPHENOLATE 500 MG TABLET MYCOPHENOLIC ACID DR 180 MG TAB MYCOPHENOLIC ACID DR 360 MG TAB 19647

13 MYFORTIC 180 MG TABLET MYFORTIC 360 MG TABLET NEORAL 100 MG GELATN CAPSULE NEORAL 100 MG/ML SOLUTION NEORAL 25 MG GELATIN CAPSULE NEVIRAPINE 200 MG TABLET NEVIRAPINE 50 MG/5 ML SUSP NEVIRAPINE ER 400 MG TABLET NORVIR 100 MG SOFTGEL CAP NORVIR 100 MG TABLET NORVIR 80 MG/ML SOLUTION PREZCOBIX MG TABLET PREZISTA 100 MG/ML SUSPENSION PREZISTA 150 MG TABLET PREZISTA 600 MG TABLET PREZISTA 75 MG TABLET PREZISTA 800 MG TABLET PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE RAPAMUNE 0.5MG TABLET RAPAMUNE 1 MG TABLET RAPAMUNE 1 MG/ML ORAL SOLN RAPAMUNE 2 MG TABLET RESCRIPTOR 100 MG TABLET RESCRIPTOR 200 MG TABLET RETROVIR 10 MG/ML SYRUP RETROVIR 10 MG/ML VIAL RETROVIR 100 MG CAPSULE REYATAZ 150 MG CAPSULE REYATAZ 200 MG CAPSULE REYATAZ 300 MG CAPSULE REYATAZ 50 MG POWDER PACKET SANDIMMUNE 100 MG CAPSULE SANDIMMUNE 100 MG/ML SOLN SANDIMMUNE 25 MG CAPSULE SELZENTRY 150 MG TABLET 98734

14 SELZENTRY 300 MG TABLET SIROLIMUS 0.5 MG TABLET SIROLIMUS 1 MG TABLET SIROLIMUS 2 MG TABLET STAVUDINE 15 MG CAPSULE STAVUDINE 20 MG CAPSULE STAVUDINE 30 MG CAPSULE STAVUDINE 40 MG CAPSULE STRIBILD TABLET SUSTIVA 200 MG CAPSULE SUSTIVA 50 MG CAPSULE SUSTIVA 600 MG TABLET TACROLIMUS 0.5 MG CAPSULE TACROLIMUS 1 MG CAPSULE TACROLIMUS 5 MG CAPSULE TIVICAY 50 MG TABLET TRIUMEQ TABLET TRIZIVIR TABLET TRUVADA 200 MG-300 MG TABLET VIDEX 2 GM PEDIATRIC SOLN VIDEX 4 GM PEDIATRIC SOLN VIDEX EC 125 MG CAPSULE VIDEX EC 200 MG CAPSULE VIDEX EC 250 MG CAPSULE VIDEX EC 400 MG CAPSULE VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VIRAMUNE 200 MG TABLET VIRAMUNE 50 MG/5 ML SUSP VIRAMUNE XR 100 MG TABLET VIRAMUNE XR 400 MG TABLET VIREAD 150 MG TABLET VIREAD 200 MG TABLET VIREAD 300 MG TABLET VIREAD POWDER VITEKTA 150 MG TABLET VITEKTA 85 MG TABLET 35807

15 ZERIT 1 MG/ML SOLUTION ZERIT 15 MG CAPSULE ZERIT 20 MG CAPSULE ZERIT 30 MG CAPSULE ZERIT 40 MG CAPSULE ZIAGEN 20 MG/ML SOLUTION ZIAGEN 300 MG TABLET ZIDOVUDINE 100 MG CAPSULE ZIDOVUDINE 300 MG TABLET ZIDOVUDINE 50 MG/5 ML SYRUP ZORTRESS 0.25 MG TABLET ZORTRESS 0.5 MG TABLET ZORTRESS 0.75 MG TABLET Label Name Step 10 (history of antineoplastic agents) Required diagnosis: 1 Look back timeframe: 730 Days GCN ALKERAN 2 MG TABLET ANASTROZOLE 1 MG TABLET ARIMIDEX 1 MG TABLET AROMASIN 25 MG TABLET AVODART 0.5 MG SOFTGEL AZACITIDINE 100 MG VIAL BICALUTAMIDE 50 MG TABLET BICNU 100 MG VIAL BOSULIF 100 MG TABLET BOSULIF 500 MG TABLET CAPECITABINE 150 MG TABLET CAPECITABINE 500 MG TABLET CAPRELSA 100 MG TABLET CAPRELSA 300 MG TABLET CASODEX 50 MG TABLET COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ 140 MG DAILY-DOSE PK 33903

16 COMETRIQ 60 MG DAILY-DOSE PK COSMEGEN 0.5 MG VIAL CYCLOPHOSPHAMIDE 25 MG CAPSULE CYCLOPHOSPHAMIDE 50 MG CAPSULE CYTARABINE 100 MG/ML VIAL CYTARABINE 1000 MG/50 ML VIAL CYTARABINE 20 MG/ML VIAL CYTARABINE 20 MG/ML VIAL CYTARABINE 20 MG/ML VIAL DROXIA 200 MG CAPSULE DROXIA 300 MG CAPSULE DROXIA 400 MG CAPSULE DUTASTERIDE 0.5 MG CAPSULE EMCYT 140 MG CAPSULE ERIVEDGE 150 MG CAPSULE ETOPOSIDE 1,000 MG/50 ML VIAL ETOPOSIDE 100 MG/5 ML VIAL ETOPOSIDE 50 MG CAPSULE ETOPOSIDE 500 MG/25 ML VIAL EVISTA 60 MG TABLET EXEMESTANE 25 MG TABLET FARESTON 60 MG TABLET FARYDAK 10 MG CAPSULE FARYDAK 15 MG CAPSULE FARYDAK 20 MG CAPSULE FEMARA 2.5 MG TABLET FINASTERIDE 5 MG TABLET FLUOROURACIL 1,000 MG/20 ML FLUOROURACIL 2.5 GM/50 ML VIAL FLUOROURACIL 5 GM/100 ML VIAL FLUOROURACIL 500 MG/10 ML VIAL FLUTAMIDE 125 MG CAPSULE GLEEVEC 100 MG TABLET GLEEVEC 400 MG TABLET 19907

17 GLEOSTINE 10 MG CAPSULE GLEOSTINE 100 MG CAPSULE GLEOSTINE 40 MG CAPSULE HEXALEN 50 MG CAPSULE HYCAMTIN 0.25 MG CAPSULE HYCAMTIN 1 MG CAPSULE HYDROXYUREA 500 MG CAPSULE IBRANCE 100 MG CAPSULE IBRANCE 125 MG CAPSULE IBRANCE 75 MG CAPSULE ICLUSIG 15 MG TABLET ICLUSIG 45 MG TABLET IMBRUVICA 140 MG CAPSULE INLYTA 1 MG TABLET INLYTA 5 MG TABLET IRESSA 250 MG TABLET LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LETROZOLE 2.5 MG TABLET LEUKERAN 2 MG TABLET LYSODREN 500 MG TABLET MATULANE 50 MG CAPSULE MEGACE 40 MG/ML ORAL SUSP MEGACE ES 625 MG/5 ML SUSP MEGESTROL 20 MG TABLET MEGESTROL 40 MG TABLET MEGESTROL ACET 40 MG/ML SUSP MEKINIST 0.5 MG TABLET MEKINIST 2 MG TABLET MERCAPTOPURINE 50 MG TABLET METHOTREXATE 2.5 MG TABLET METHOTREXATE 25 MG/ML VIAL 18936

18 METHOTREXATE 25 MG/ML VIAL MITOMYCIN 20 MG VIAL MITOMYCIN 5 MG VIAL MITOXANTRONE 20 MG/10 ML VIAL MITOXANTRONE 25 MG/12.5 ML VL MITOXANTRONE 30 MG/15 ML VIAL MYLERAN 2 MG TABLET NEXAVAR 200 MG TABLET NILANDRON 150 MG TABLET ONCASPAR 750 UNIT/ML VIAL PROSCAR 5 MG TABLET PURIXAN 20 MG/ML ORAL SUSPENSION RALOXIFENE HCL 60 MG TABLET RHEUMATREX 2.5 MG TABLET SOLTAMOX 10 MG/5 ML SOLN SPRYCEL 100 MG TABLET SPRYCEL 140 MG TABLET SPRYCEL 20 MG TABLET SPRYCEL 50 MG TABLET SPRYCEL 70 MG TABLET SPRYCEL 80 MG TABLET SUTENT 12.5 MG CAPSULE SUTENT 25 MG CAPSULE SUTENT 37.5 MG CAPSULE SUTENT 50 MG CAPSULE SYNRIBO 3.5 MG/ML VIAL TABLOID 40 MG TABLET TAMOXIFEN 10 MG TABLET TAMOXIFEN 20 MG TABLET TARCEVA 100 MG TABLET TARCEVA 150 MG TABLET TARCEVA 25 MG TABLET TARGRETIN 75 MG SOFTGEL TASIGNA 150 MG CAPSULE 28737

19 TASIGNA 200 MG CAPSULE TEMODAR 100 MG CAPSULE TEMODAR 140 MG CAPSULE TEMODAR 180 MG CAPSULE TEMODAR 20 MG CAPSULE TEMODAR 250 MG CAPSULE TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE 5 MG CAPSULE TENIPOSIDE 50 MG/5 ML AMPULE TREXALL 10 MG TABLET TREXALL 15 MG TABLET TREXALL 5 MG TABLET TREXALL 7.5 MG TABLET TYKERB 250 MG TABLET VINBLASTINE 1 MG/ML VIAL VINCRISTINE 1 MG/ML VIAL VINCRISTINE 2 MG/2 ML VIAL VOTRIENT 200 MG TABLET XALKORI 200 MG CAPSULE XALKORI 250 MG CAPSULE XELODA 150 MG TABLET XELODA 500 MG TABLET XTANDI 40 MG CAPSULE ZELBORAF 240 MG TABLET ZOLINZA 100 MG CAPSULE ZYDELIG 100 MG TABLET ZYDELIG 150 MG TABLET ZYKADIA 150 MG CAPSULE ZYTIGA 250 MG TABLET 29886

20 Step 11 (diagnosis of skin absorption disorder or skin malignancy) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 1720 MALIGNANT MELANOMA OF SKIN OF LIP 1721 MALIGNANT MELANOMA OF SKIN OF EYELID, INCLUDING CANTHUS 1722 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 1723 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE 1724 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK 1725 MALIGNANT MELANOMA OF SKIN OF TRUNK, EXCEPT SCROTUM 1726 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER 1727 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB, INCLUDING HIP 1728 MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN 1729 MELANOMA OF SKIN, SITE UNSPECIFIED 1760 KAPOSI'S SARCOMA, SKIN UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP BASAL CELL CARCINOMA OF SKIN OF LIP SQUAMOUS CELL CARCINOMA OF SKIN OF LIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

21 17331 BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED

22 17399 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES PERIPHERAL T CELL LYMPHOMA, SPLEEN PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 7571 ICHTHYOSIS CONGENITA ICD-10 Code C430 C4310 C4311 C4312 C4320 C4321 C4322 C4330 C4331 C4339 C434 C4351 C4352 C4359 C4360 C4361 C4362 Description MALIGNANT MELANOMA OF LIP MALIGNANT MELANOMA OF UNSPECIFIED EYELID, INCLUDING CANTHUS MALIGNANT MELANOMA OF RIGHT EYELID, INCLUDING CANTHUS MALIGNANT MELANOMA OF LEFT EYELID, INCLUDING CANTHUS MALIGNANT MELANOMA OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL MALIGNANT MELANOMA OF RIGHT EAR AND EXTERNAL AURICULAR CANAL MALIGNANT MELANOMA OF LEFT EAR AND EXTERNAL AURICULAR CANAL MALIGNANT MELANOMA OF UNSPECIFIED PART OF FACE MALIGNANT MELANOMA OF NOSE MALIGNANT MELANOMA OF OTHER PARTS OF FACE MALIGNANT MELANOMA OF SCALP AND NECK MALIGNANT MELANOMA OF ANAL SKIN MALIGNANT MELANOMA OF SKIN OF BREAST MALIGNANT MELANOMA OF OTHER PART OF TRUNK MALIGNANT MELANOMA OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER MALIGNANT MELANOMA OF RIGHT UPPER LIMB, INCLUDING SHOULDER MALIGNANT MELANOMA OF LEFT UPPER LIMB, INCLUDING SHOULDER

23 C4370 C4371 C4372 C438 C439 C4400 C4401 C4402 C4409 C44101 C44102 C44109 C44111 C44112 C44119 C44121 C44122 C44129 C44191 C44192 C44199 C44201 C44202 C44209 MALIGNANT MELANOMA OF UNSPECIFIED LOWER LIMB, INCLUDING HIP MALIGNANT MELANOMA OF RIGHT LOWER LIMB, INCLUDING HIP MALIGNANT MELANOMA OF LEFT LOWER LIMB, INCLUDING HIP MALIGNANT MELANOMA OF OVERLAPPING SITES OF SKIN MALIGNANT MELANOMA OF SKIN, UNSPECIFIED UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP BASAL CELL CARCINOMA OF SKIN OF LIP SQUAMOUS CELL CARCINOMA OF SKIN OF LIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED EYELID, INCLUDING CANTHUS UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT EYELID, INCLUDING CANTHUS UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT EYELID, INCLUDING CANTHUS BASAL CELL CARCINOMA OF SKIN OF UNSPECIFIED EYELID, INCLUDING CANTHUS BASAL CELL CARCINOMA OF SKIN OF RIGHT EYELID, INCLUDING CANTHUS BASAL CELL CARCINOMA OF SKIN OF LEFT EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA OF SKIN OF UNSPECIFIED EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA OF SKIN OF RIGHT EYELID, INCLUDING CANTHUS SQUAMOUS CELL CARCINOMA OF SKIN OF LEFT EYELID, INCLUDING CANTHUS OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED EYELID, INCLUDING CANTHUS OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT EYELID, INCLUDING CANTHUS OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT EYELID, INCLUDING CANTHUS UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT EAR AND EXTERNAL AURICULAR CANAL UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT EAR AND EXTERNAL AURICULAR CANAL

24 C44211 C44212 C44219 C44221 C44222 C44229 C44291 C44292 C44299 C44300 C44301 C44309 C44310 C44311 C44319 C44320 C44321 C44329 C44390 C44391 C44399 C4440 C4441 BASAL CELL CARCINOMA OF SKIN OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL BASAL CELL CARCINOMA OF SKIN OF RIGHT EAR AND EXTERNAL AURICULAR CANAL BASAL CELL CARCINOMA OF SKIN OF LEFT EAR AND EXTERNAL AURICULAR CANAL SQUAMOUS CELL CARCINOMA OF SKIN OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL SQUAMOUS CELL CARCINOMA OF SKIN OF RIGHT EAR AND EXTERNAL AURICULAR CANAL SQUAMOUS CELL CARCINOMA OF SKIN OF LEFT EAR AND EXTERNAL AURICULAR CANAL OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT EAR AND EXTERNAL AURICULAR CANAL OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT EAR AND EXTERNAL AURICULAR CANAL UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED PART OF FACE UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF NOSE UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER PARTS OF FACE BASAL CELL CARCINOMA OF SKIN OF UNSPECIFIED PARTS OF FACE BASAL CELL CARCINOMA OF SKIN OF NOSE BASAL CELL CARCINOMA OF SKIN OF OTHER PARTS OF FACE SQUAMOUS CELL CARCINOMA OF SKIN OF UNSPECIFIED PARTS OF FACE SQUAMOUS CELL CARCINOMA OF SKIN OF NOSE SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER PARTS OF FACE OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED PARTS OF FACE OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF NOSE OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER PARTS OF FACE UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF SCALP AND NECK BASAL CELL CARCINOMA OF SKIN OF SCALP AND NECK

25 C4442 C4449 C44500 C44501 C44509 C44510 C44511 C44519 C44520 C44521 C44529 C44590 C44591 C44599 C44601 C44602 C44609 C44611 C44612 C44619 C44621 C44622 C44629 C44691 C44692 SQUAMOUS CELL CARCINOMA OF SKIN OF SCALP AND NECK OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF SCALP AND NECK UNSPECIFIED MALIGNANT NEOPLASM OF ANAL SKIN UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF BREAST UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER PART OF TRUNK BASAL CELL CARCINOMA OF ANAL SKIN BASAL CELL CARCINOMA OF SKIN OF BREAST BASAL CELL CARCINOMA OF SKIN OF OTHER PART OF TRUNK SQUAMOUS CELL CARCINOMA OF ANAL SKIN SQUAMOUS CELL CARCINOMA OF SKIN OF BREAST SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER PART OF TRUNK OTHER SPECIFIED MALIGNANT NEOPLASM OF ANAL SKIN OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF BREAST OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER PART OF TRUNK UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT UPPER LIMB, INCLUDING SHOULDER UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT UPPER LIMB, INCLUDING SHOULDER BASAL CELL CARCINOMA OF SKIN OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER BASAL CELL CARCINOMA OF SKIN OF RIGHT UPPER LIMB, INCLUDING SHOULDER BASAL CELL CARCINOMA OF SKIN OF LEFT UPPER LIMB, INCLUDING SHOULDER SQUAMOUS CELL CARCINOMA OF SKIN OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER SQUAMOUS CELL CARCINOMA OF SKIN OF RIGHT UPPER LIMB, INCLUDING SHOULDER SQUAMOUS CELL CARCINOMA OF SKIN OF LEFT UPPER LIMB, INCLUDING SHOULDER OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT UPPER LIMB, INCLUDING SHOULDER

26 C44699 C44701 C44702 C44709 C44711 C44712 C44719 C44721 C44722 C44729 C44791 C44792 C44799 C4480 C4481 C4482 C4489 C4490 C4491 C4492 C4499 C460 C8440 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT UPPER LIMB, INCLUDING SHOULDER UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED LOWER LIMB, INCLUDING HIP UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT LOWER LIMB, INCLUDING HIP UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT LOWER LIMB, INCLUDING HIP BASAL CELL CARCINOMA OF SKIN OF UNSPECIFIED LOWER LIMB, INCLUDING HIP BASAL CELL CARCINOMA OF SKIN OF RIGHT LOWER LIMB, INCLUDING HIP BASAL CELL CARCINOMA OF SKIN OF LEFT LOWER LIMB, INCLUDING HIP SQUAMOUS CELL CARCINOMA OF SKIN OF UNSPECIFIED LOWER LIMB, INCLUDING HIP SQUAMOUS CELL CARCINOMA OF SKIN OF RIGHT LOWER LIMB, INCLUDING HIP SQUAMOUS CELL CARCINOMA OF SKIN OF LEFT LOWER LIMB, INCLUDING HIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UNSPECIFIED LOWER LIMB, INCLUDING HIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF RIGHT LOWER LIMB, INCLUDING HIP OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LEFT LOWER LIMB, INCLUDING HIP UNSPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF SKIN BASAL CELL CARCINOMA OF OVERLAPPING SITES OF SKIN SQUAMOUS CELL CARCINOMA OF OVERLAPPING SITES OF SKIN OTHER SPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF SKIN UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, UNSPECIFIED BASAL CELL CARCINOMA OF SKIN, UNSPECIFIED SQUAMOUS CELL CARCINOMA OF SKIN, UNSPECIFIED OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, UNSPECIFIED KAPOSI'S SARCOMA OF SKIN PERIPHERAL T-CELL LYMPHOMA, UNSPECIFIED SITE

27 C8441 C8442 C8443 C8444 C8445 C8446 C8447 C8448 C8449 D030 D0310 D0311 D0312 D0320 D0321 D0322 D0330 D0339 D034 D0351 D0352 D0359 D0360 D0361 D0362 D0370 D0371 D0372 D038 PERIPHERAL T-CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK PERIPHERAL T-CELL LYMPHOMA, INTRATHORACIC LYMPH NODES PERIPHERAL T-CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES PERIPHERAL T-CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB PERIPHERAL T-CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB PERIPHERAL T-CELL LYMPHOMA, INTRAPELVIC LYMPH NODES PERIPHERAL T-CELL LYMPHOMA, SPLEEN PERIPHERAL T-CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES PERIPHERAL T-CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES MELANOMA IN SITU OF LIP MELANOMA IN SITU OF UNSPECIFIED EYELID, INCLUDING CANTHUS MELANOMA IN SITU OF RIGHT EYELID, INCLUDING CANTHUS MELANOMA IN SITU OF LEFT EYELID, INCLUDING CANTHUS MELANOMA IN SITU OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL MELANOMA IN SITU OF RIGHT EAR AND EXTERNAL AURICULAR CANAL MELANOMA IN SITU OF LEFT EAR AND EXTERNAL AURICULAR CANAL MELANOMA IN SITU OF UNSPECIFIED PART OF FACE MELANOMA IN SITU OF OTHER PARTS OF FACE MELANOMA IN SITU OF SCALP AND NECK MELANOMA IN SITU OF ANAL SKIN MELANOMA IN SITU OF BREAST (SKIN) (SOFT TISSUE) MELANOMA IN SITU OF OTHER PART OF TRUNK MELANOMA IN SITU OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER MELANOMA IN SITU OF RIGHT UPPER LIMB, INCLUDING SHOULDER MELANOMA IN SITU OF LEFT UPPER LIMB, INCLUDING SHOULDER MELANOMA IN SITU OF UNSPECIFIED LOWER LIMB, INCLUDING HIP MELANOMA IN SITU OF RIGHT LOWER LIMB, INCLUDING HIP MELANOMA IN SITU OF LEFT LOWER LIMB, INCLUDING HIP MELANOMA IN SITU OF OTHER SITES

28 D039 Q802 Q803 Q808 Q809 MELANOMA IN SITU, UNSPECIFIED LAMELLAR ICHTHYOSIS CONGENITAL BULLOUS ICHTHYOSIFORM ERYTHRODERMA OTHER CONGENITAL ICHTHYOSIS CONGENITAL ICHTHYOSIS, UNSPECIFIED Step 12 (history of prior pimecrolimus/tacrolimus prescription 180 days) Required quantity: 1 Look back timeframe: 200 Days See the Topical Pimecrolimus/Tacrolimus Drugs table in Step 7.

29 Protopic 0.1% Drugs Requiring Label Name GCN PROTOPIC 0.1% OINTMENT TACROLIMUS 0.1% OINTMENT Clinical Edit Criteria Logic 1. Does the client have a diagnosis of localized skin graft versus host disease in the last 365 days? (Go to #2) (Go to #3) 2. Has the client had a bone marrow transplant in the last 365 days? (Approve 365 days) (Go to #3) 3. Is the client < 16 years of age? () (Go to #4) 4. Does the client have a diagnosis of Atopic Dermatitis (eczema) in the last 730 days? (Go to #5) () 5. Does the client have a history of a topical steroid or nystatin / triamcinolone prescription in the last 730 days? (Go to #7) (Go to #6) 6. Does the client have a history of a prior pimecrolimus (ELIDEL) / tacrolimus (PROTOPIC) prescription in the last 365 days? (Go to #7) () 7. Has the client had a diagnosis of HIV or Immune System Disorder in the last 730 days? () (Go to #8) 8. Does the client have a history of HIV drugs or immunosuppressants in the last 730 days? () (Go to #9) 9. Does the client have a history of antineoplastic agents in the last 730 days? () (Go to #10) 10. Does the client have a history of a skin absorption disorder or a skin malignancy in the last 730 days? () (Go to #11) 11. Does the client have a history of a prior pimecrolimus (ELIDEL) / tacrolimus (PROTOPIC) prescription 180 days in the last 200 days? (Approve 180 days) ()

30 Protopic 0.1% Clinical Edit Criteria Logic Diagram Step 1: Does the client have a diagnosis of localized skin graft versus host disease in the last 365 days? Clinical Edit Criteria Supporting Tables Step 2 see Step 3 in section above Step 3 see Step 2 in Elidel and Protopic 0.03% section above Step 4 see Step 5 in section above Step 5 see Step 6 in section above Step 3: Step 6 see Step Is 7 the in client Elidel < 16 years and of Protopic age? 0.03% section above Step 7 see Step 8 in section above Step 8 see Step 9 in section above Step 9 see Step 5 in section above Step 4: Does the client have a diagnosis of Atopic Dermatitis (eczema) in the last 730 days? Step 2: Has the client had a bone marrow transplant in the last 365 days? Approve for 365 days Step 5: Does the client have a history of a topical steroid or nystatin/triamcinolone prescription in the last 730 days? Step 6: Does the client have a history of a prior pimecrolimus (ELIDEL)/tacrolimus (PROTOPIC) prescription in the last 365 days? Step 7: Has the client had a diagnosis of HIV or Immune System Disorder in the last 730 days? Step 8: Does the client have a history of HIV drugs or immunosuppressants in the last 730 days? Step 9: Does the client have a history of antineoplastic agents in the last 730 days? Step 10: Does the client have a history of a skin absorption disorder or a skin malignancy in the last 730 days? Step 11: Does the client have a history of a prior pimecrolimus (ELIDEL)/tacrolimus (PROTOPIC) prescription less than or equal to 180 days in the last 200 days? Approve for 180 days

31 Protopic 0.1% Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of graft-versus-host disease) Required diagnosis: 1 Look back timeframe: 365 Days see Step 1 in section above Step 2 (history of bone marrow transplant) Required code: 1 Look back timeframe: 365 Days see Step 2 in section above Step 4 (diagnosis of atopic dermatitis) Required diagnosis: 1 Look back timeframe: 730 Days see Step 5 in section above Step 5 (history of a topical steroid) Required quantity: 1 Look back timeframe: 730 Days see Step 4 in section above Step 6 (history of a prior pimecrolimus/tacrolimus prescription) Required quantity: 1 Look back timeframe: 365 Days see Step 7 in section above Step 7 (diagnosis of HIV or immune system disorder) Required quantity: 1 Look back timeframe: 730 Days see Step 8 in section above Step 8 (history of HIV drugs or immunosuppressants) Required quantity: 1 Look back timeframe: 730 Days see Step 9 in section above Step 9 (history of antineoplastic agents) Required diagnosis: 1 Look back timeframe: 730 Days see Step 10 in section above Step 10 (diagnosis of skin absorption disorder or skin malignancy) Required diagnosis: 1 Look back timeframe: 730 days see Step 11 in section above Step 11 (history of a prior pimecrolimus/tacrolimus prescription) Required quantity: 1 Look back timeframe: 200 Days see Step 7 in section above

32 Eucrisa Drugs Requiring Label Name GCN EUCRISA 2% OINTMENT Clinical Edit Criteria Logic 1. Is the client less than (<) 2 years of age? () (Go to #2) 2. Does the client have a diagnosis of Atopic Dermatitis (eczema) in the last 730 days? (Go to #3) () 3. Does the client have a claim for a topical steroid in the last 730 days? (Approve 180 days) ()

33 Eucrisa Clinical Edit Criteria Logic Diagram Step 1: Is the client < 2 years of age? Step 2: Does the client have a diagnosis of Atopic Dermatitis (eczema) in the last 730 days? Step 3: Does the client have a claim for a topical steroid in the last 730 days? Approve Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of atopic dermatitis) Required diagnosis: 1 Look back timeframe: 730 Days see Step 5 in section above Step 3 (history of a topical steroid) Required quantity: 1 Look back timeframe: 730 Days see Step 4 in section above

34 Clinical Criteria References ICD-9-CM Diagnosis Codes Available at Accessed on April 3, ICD-10-CM Diagnosis Codes Available at Accessed on April 3, American Medical Association data files ICD-9-CM Diagnosis Codes. Available at 4. American Medical Association data files ICD-10-CM Diagnosis Codes. Available at 5. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on April 13, Micromedex [online database]. Available at Accessed on April 13, Elidel Prescribing Information. Bridgewater, NJ. Valeant Pharmaceuticals rth America LLC. August Protopic Prescribing Information. rthbrook, IL. Astellas Pharma US, Inc. vember Eucrisa Prescribing Information. Palo Alto, CA. Anacor Pharmaceuticals. December Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis. J Am Acad Dermatology Jul;71(1): Wahn U, Bos JD, Goodfield M, Caputo R, Papp K, Manjra A, et al. Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002;110:e Kapp A, Papp K, Bingham A, Folster-Holst R, Ortonne JP, Potter PC, et al. Long-termmanagement of atopic dermatitis in infants with topical pimecrolimus, a nonsteroid anti-inflammatory drug. J Allergy Clin Immunol 2002;110: Thaci D, Chambers C, Sidhu M, Dorsch B, Ehlken B, Fuchs S. Twice-weekly treatment with tacrolimus 0.03% ointment in children with atopic dermatitis: clinical efficacy and economic impact over 12 months. J Eur Acad Dermatol Venereol 2010;24: Koo JY, Fleischer AB Jr, Abramovits W, Pariser DM, McCall CO, Horn TD, et al. Tacrolimus ointment is safe and effective in the treatment of atopic dermatitis: results in 8000 patients. J Am Acad Dermatol 2005;53(Suppl):S

35 Publication History Publication Date tes 04/05/12 Initial publication Added ICD-10 diagnosis codes Added additional medications in steps 7 and 8 07/21/16 Updated dates Added additional Clinical Edit Criteria References 12/04/16 Added Tacrolimus to the Drugs Requiring Updated GCNs in Step 7 table Updated GCNs in Step 8 table 02/22/17 05/31/2017 Added a skin absorption disorder or a skin malignancy question to both the Elidel/Protopic.03% section and the Protopic 1% section Updated both clinical edit logic diagrams Updated Step 8 table Added Step 9 table for skin absorption disorder or a skin malignancy diagnoses Updated Table 3 removed ICD-9/10s for diaper rash/dermatitis Added criteria for Eucrisa Added GCN for Eucrisa to Drugs Requiring PA Added criteria logic for Eucrisa Added logic diagram for Eucrisa Added supporting tables for Eucrisa Updated references Added criteria for Added criteria logic for Protopic 0.1% Updated logic diagram for Updated logic diagram for Protopic 0.1% Added supporting tables for Added supporting tables for Protopic 0.1%

Topical Immunomodulators

Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Topical Immunomodulators Clinical Edit Information Included in this Document Topical Immunomodulators Elidel and Protopic 0.03%