CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Elidel Pa With Logic Policy 76 D Udr 04 2023

Defines prior authorization (PA) screen-out logic and clinical coverage criteria for Elidel (pimecrolimus) cream 1% for indications including atopic dermatitis, psoriasis (face/genitals/folds), and vitiligo on head/neck; includes continuation and initiation criteria and requirement to have tried medium-or-higher potency topical corticosteroid under the prescription benefit for screen-out.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyElidel Pa With Logic Policy 76 D Udr 04 2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf the patient has not filled at least a 14-day supply of a medium-or-higher potency topical corticosteroid within the past 180 days under CVS Caremark, the claim will reject indicating prior authorization is required and the PA criteria will be applied upon PA submission.

SourceLink

POLICY UPDATE CHANGES

No material changes — policy has no listed updates.

3Covered Indications (listed)

180Look-back days for corticosteroid fill

14Minimum corticosteroid supply (days)

Coverage Summary & Criteria

Referenced productmixed

ELIDEL

Brand name pimecrolimus cream 1%

Topical corticosteroid examples (screen-out logic reference)mixed

betamethasone dipropionate lotion/spray 0.05%	Example medium potency topical corticosteroid
betamethasone valerate crm/lotion 0.1%/foam 0.12%	Example medium potency topical corticosteroid
clocortolone pivalate crm 0.1%	Example medium potency topical corticosteroid
desonide lotion/ointment 0.05%	Example medium potency topical corticosteroid
desoximetasone crm 0.05%	Example medium potency topical corticosteroid
fluocinolone acetonide crm/oint 0.025%	Example medium potency topical corticosteroid
flurandrenolide crm/oint/lotion 0.05%	Example medium potency topical corticosteroid
fluticasone propionate crm/lotion 0.05%/oint 0.005%	Example medium potency topical corticosteroid
hydrocortisone butyrate cream/lotion/ointment/soln 0.1%	Example medium potency topical corticosteroid
hydrocortisone probutate crm 0.1%	Example medium potency topical corticosteroid

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Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization required if screen-out not met

If the patient has not filled at least a 14-day supply of a medium-or-higher potency topical corticosteroid within the past 180 days under the CVS Caremark prescription benefit, the claim will reject indicating prior authorization is required and the PA criteria will be applied upon PA submission.

Automated screen-out: claim pays under prescription benefit if there is a fill for at least a 14-day supply of a medium-or-higher potency topical corticosteroid within the prior 180 days; otherwise the claim rejects and PA is required (see examples of medium/high/very high potency corticosteroids in Table 1).

Documentation Required

Documentation of inadequate response or positive clinical response

For new therapy when required (e.g., atopic dermatitis on sensitive areas) document inadequate response, intolerance, or contraindication to at least one first-line agent (medium or higher potency topical corticosteroid). For requests for continuation of therapy, document a positive clinical response.

Examples of acceptable documentation of inadequate response: trial notes or prescription history showing use of at least one medium-or-higher potency topical corticosteroid (minimum 14-day supply where applicable) with ongoing signs/symptoms or clinician statement that the agent was ineffective, not tolerated, or contraindicated.
Examples of acceptable documentation of positive clinical response for continuation: clinician assessment documenting clear or almost clear outcome, meaningful repigmentation (for vitiligo), patient satisfaction, or improvement/resolution of signs or symptoms such as erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus.

Operational note — screen-out logic: an automated claims check will look back 180 days for a filled prescription of at least a 14-day supply of a medium-or-higher potency topical corticosteroid under the CVS Caremark prescription benefit. If that criterion is met, the request will be paid under the prescription benefit; if not, the claim will reject indicating prior authorization is required and the PA criteria will be applied.

Background & Scope

Elidel (pimecrolimus) Cream 1% is FDA-indicated as a second-line agent for the short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children aged ≥2 years who have failed other topical prescription treatments or when those treatments are not advisable. The FDA label specifies it is not indicated for children under 2 years of age.

Compendial uses included in the policy list treatment of psoriasis located on the face, genitals, or skin folds, atopic dermatitis for patients <2 years of age (compendial), and vitiligo on the head or neck. Where applicable, the policy limits the FDA-indicated population to non-immunocompromised patients aged ≥2 years.