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Elidel (pimecrolimus cream) — Blue Cross Blue Shield of New Mexico

atopic dermatitis

Initial criteria

  • Target Agent(s) will be approved when ONE of the following is met:
  • 1. The requested agent is for use on the face (including eyelids), neck, or skin folds (e.g., groin, armpit/under arm) OR
  • 2. The requested agent is eligible for continuation of therapy AND the following:
  • A. The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy has changed OR
  • 3. The prescriber states the patient is currently being treated with a requested agent AND the patient is currently stable on the requested agent [chart notes are required] OR
  • 4. The patient has tried and had an inadequate response to ONE topical corticosteroid or topical corticosteroid combination preparation [chart notes are required] OR
  • 5. ONE topical corticosteroid or topical corticosteroid combination preparation was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required] OR
  • 6. The patient has an intolerance or hypersensitivity to ONE topical corticosteroid or topical corticosteroid combination preparation [chart notes are required] OR
  • 7. The patient has an FDA labeled contraindication to ALL topical corticosteroids AND all topical corticosteroid combination preparations [chart notes are required] OR
  • 8. ONE topical corticosteroid or topical corticosteroid combination preparation is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm [chart notes are required] OR
  • 9. ONE topical corticosteroid or topical corticosteroid combination preparation is not in the best interest of the patient based on medical necessity [chart notes are required] OR
  • 10. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as ONE topical corticosteroid or topical corticosteroid combination preparation and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required]

Reauthorization criteria

  • Agents eligible for continuation of therapy: all target agents are eligible; prescriber states patient has been treated with the requested agent within past 90 days and is at risk if therapy changed.

Approval duration

12 months