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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)
PDF Format
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Last Revised: January 22, 2008
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