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Identifying FWA with Elidel and Protopic-Are they too young?
Did you know that the topical drugs Elidel and Protopic are not indicated for children under the age of 2? To identify inappropriate prescribing/dispensing, SIU Investigators and/or pharmacy auditors should regularly review their claims for these medications.
What is Elidel and Protopic?
Elidel (pimecrolimus) Cream, 1% [1] is 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. The safety of Elidel Cream has not been established beyond one year of non-continuous use. Application should be limited to areas of involvement with atopic dermatitis.
Elidel Cream, 1% [2] is available in these sizes:
30 gram tube - NDC 00187-5100-01
60 gram tube - NDC 00187-5101-02
100 gram tube - NDC 00187-5102-03
Protopic (tacrolimus) Ointment, both 0.03% and 0.1% [3] for adults, and only 0.03% for children aged 2 to 15 years, is indicated as second-line therapy for the short-term and non-continuous chronic treatment of moderate to severe atopic dermatitis in non-immunocompromised adults and children who have failed to respond adequately to other topical prescription treatments for atopic dermatitis, or when those treatments are not advisable.
Protopic Ointment [4] is available in these strengths and sizes:
0.03%
- 30 gram laminate tube - NDC 00469-5201-30
- 60 gram laminate tube - NDC 00469-5201-60
- 100 gram laminate tube - NDC 00469-5201-11
0.1%
- 30 gram laminate tube - NDC 00469-5202-30
- 60 gram laminate tube - NDC 00469-5202-60
- 100 gram laminate tube - NDC 00469-5202-11
Plan Example:
Oklahoma Health Care Authority [5] (OKHCA) put in place a Prior Authorization (PA) criteria for their members on Elidel and Protopic claims. One of the criteria set forth is on Age Restrictions:
- Elidel 1% ≥ 2 years of age
- Protopic 0.03% for ≥ 2 years of age
- Protopic 0.1% for ≥ 15 years of age (Approved for adult-use only)
Since OKHCA has that criteria in place, all claims for Elidel 1% and Protopic 0.03% processed for members under the age of 2 should deny at the point of service.
What to look for?
SIU Investigators and pharmacy auditors can data mine using software such as PostShield to identify members obtaining Elidel and Protopic 0.03% who may not be eligible depending on the Plan's policies. The investigator should always verify the member's date of birth to verify the medications were prescribed and dispensed according to their company's policy. If risks are identified, the SIU Investigators and/or pharmacy auditors should contact the Plan Administrator and recommend that an "Age Edit" be established for these medications. Provider education may also be warranted.
Did you know that Healthcare Fraud Shield also has the ability to integrate your pharmacy claims with your medical data to help identify various schemes? If you have any questions, please email us at [email protected].
REFERENCES
[1] Elidel
[2] Elidel
[3] Protopic
[4] Protopic
[5] OKHCA
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