Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
pimecrolimus cream

Criteria Approval Period
Diagnosis of eczema

PLUS

Medication prescribed by a dermatologist

PLUS one of the following:

•  Patient is refractory to three months of specified potent topical corticosteroid therapy

   OR

•  Patient is intolerant to specified topical corticosteroid treatment. 		Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Potent corticosteroid medication to be specified

Special Authority Form

A dermatologist should complete the request form below.
Special Authority Request Form (PDF)