Elidel (pimecrolimus) cream 1% — Highmark

Initial criteria

• age ≥ 2 years
• diagnosis of atopic dermatitis (ICD-10: L20) classified as mild to moderate
• member has experienced therapeutic failure, contraindication, or intolerance to at least one topical prescription corticosteroid OR has atopic dermatitis with facial or anogenital involvement
• IF requesting brand Elidel THEN member has experienced therapeutic failure or intolerance to generic topical tacrolimus OR generic topical pimecrolimus

Reauthorization criteria

• member has experienced a positive clinical response to therapy

Approval duration

up to 12 months