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Elidel (pimecrolimus cream) — Blue Cross Blue Shield of Texas

Atopic dermatitis

Preferred products

  • tacrolimus ointment

Initial criteria

  • Target agent 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 all of 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 required] OR
  • 4. The patient has tried and had an inadequate response to ONE topical corticosteroid or topical corticosteroid combination preparation [chart notes 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 required] OR
  • 6. The patient has an intolerance or hypersensitivity to ONE topical corticosteroid or topical corticosteroid combination preparation [chart notes required] OR
  • 7. The patient has an FDA labeled contraindication to ALL topical corticosteroids AND all topical corticosteroid combination preparations [chart notes required] OR
  • 8. ONE topical corticosteroid or topical corticosteroid combination preparation is expected to be ineffective based on known clinical characteristics of the patient and the drug; OR cause a significant barrier to adherence; OR worsen a comorbid condition; OR decrease ability to perform daily activities; OR cause an adverse reaction or harm [chart notes 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 required] OR
  • 10. The patient has tried another prescription drug in the same pharmacologic class or mechanism as ONE topical corticosteroid or topical corticosteroid combination preparation and that drug was discontinued due to lack of efficacy or adverse event [chart notes required]

Reauthorization criteria

  • Continuation of therapy allowed when the prescriber states patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR the patient is currently stable on therapy.

Approval duration

12 months