CurrentNeighborhood Health Plan of Rhode IslandPolicy 76-D

Pimecrolimus (Elidel) prior authorization

Defines prior authorization and coverage criteria for Elidel (pimecrolimus) cream 1% for atopic dermatitis, psoriasis (sensitive areas), and vitiligo (head/neck) under the payer's prescription benefit; affects prescribers and pharmacy PA reviewers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPimecrolimus (Elidel) prior authorization

Policy CodePolicy 76-D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when the screen-out logic is not met and document indication, prior topical corticosteroid use or exception, and clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1%Formulation strength

>=2 yrsFDA min age

3 moInitial DOA

36 moContinuation DOA

14 daysCorticosteroid fill

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Atopic Dermatitis - Initial Therapy

Authorization may be granted when the requested drug is being prescribed for short-term and noncontinuous chronic treatment of mild to moderate atopic dermatitis when ONE of the following is met:

Atopic Dermatitis initial criteria: Patient is less than 2 years of age.

FDA minimum age and policy exception noted.

Atopic Dermatitis initial criteria: Requested drug will be used on sensitive skin areas (e.g., face, genitals, or skin folds).

Sensitive-area use qualifies for initial authorization.

Atopic Dermatitis initial criteria: Patient has experienced an inadequate treatment response, intolerance, or contraindication to at least ONE first-line therapy agent (e.g., medium or higher potency topical corticosteroid).

Step therapy requirement: prior use or failure of medium-or-higher potency topical corticosteroid unless exception applies.

Atopic Dermatitis - Continuation Therapy

Authorization may be granted for continuation when ALL of the following are met:

Atopic Dermatitis continuation criteria: Patient has achieved or maintained a positive clinical response as evidenced by improvement in signs or symptoms (e.g., erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, OR pruritus).

Documentation of clinical improvement required for continuation.

Atopic Dermatitis continuation criteria: Duration of therapy consistent with policy: for patients 2 years of age and older initial approval up to 3 months with continuation approvals per policy (see Duration of Approval).

Continuation approvals guided by DOA table.

Psoriasis (sensitive areas)

Authorization may be granted when the requested drug is being prescribed for psoriasis on the face, genitals, or skin folds.

Psoriasis sensitive area criteria: Prescription is for psoriasis located on the face, genitals, or skin folds.

Compendial use supported for sensitive skin areas where topical corticosteroid potency is limited.

Vitiligo (head/neck)

Authorization may be granted when the requested drug is being prescribed for vitiligo on the head or neck.

Vitiligo head/neck criteria: Prescription is for vitiligo located on the head or neck.

Compendial use supported for head/neck vitiligo.

Psoriasis and Vitiligo - Continuation

Authorization may be granted for continuation when the following is met:

Continuation for psoriasis: Patient has achieved or maintained a positive clinical response (e.g., clear or almost clear outcome, patient satisfaction).

Documented clinical improvement required for continued coverage.

Continuation for vitiligo: Patient has achieved or maintained a positive clinical response as evidenced by meaningful repigmentation.

Documented repigmentation required for continued coverage.

Elidel (pimecrolimus) cream, 1%, is FDA-indicated as second-line therapy for the short-term and noncontinuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised patients. The FDA approval applies to adults and children aged 2 years and older; Elidel is not indicated for use in children younger than 2 years of age.

Provider Actions and Prior Authorization

Prior Authorization

Screen‑out / PA trigger

Claims will be screened for recent topical corticosteroid use under the member's prescription benefit. If the member has not filled at least a 14‑day supply of a medium‑ or higher‑potency topical corticosteroid within the past 180 days, the claim will reject with a message indicating that a prior authorization (PA) is required. Requests that fail the screen‑out are subject to PA review under the authorization criteria.

Includes prescription and OTC products unless otherwise stated.
Screening looks at prescription benefit fills administered by CVS Caremark.
Required recent use: ≥ 14‑day supply of a medium or higher potency topical corticosteroid within 180 days.

Prior Authorization

Prior authorization required when screen‑out not met

Prior authorization is required when the screen‑out is not met. Additionally, PA review will apply when the drug is being considered for short‑term or noncontinuous chronic treatment of mild to moderate atopic dermatitis and the member meets clinical criteria submitted to the PA unit.

PA required when claim rejects due to failure to meet the topical corticosteroid screen‑out.
PA requests must document the clinical indication and prior treatments (see documentation callout).
Authorization may be granted when ONE of the atopic dermatitis criteria is met: age <2 years; use on sensitive areas (face, genitals, skin folds); or inadequate response/intolerance/contraindication to ≥1 first‑line agent (e.g., medium+ potency topical corticosteroid).

Step Therapy

Topical corticosteroid step

Step therapy: prior use of a medium or higher potency topical corticosteroid is required before approval in many cases. Specifically, documentation of a prior fill for a ≥14‑day supply of a medium+ potency topical corticosteroid within the past 180 days supports approval and prevents PA trigger via the screen‑out logic.

Step requirement = prior use of medium or higher potency topical corticosteroid (≥14‑day supply in past 180 days).
If step not met, claim will reject and PA will be required to demonstrate clinical necessity.

Documentation Required

Required documentation

When submitting a PA after a screen‑out rejection, include documentation to support the diagnosis and prior treatments. At minimum, provide: description of clinical signs/symptoms and response to therapy; dates and details of prior topical corticosteroid use (agent, potency, supply/duration, and fill dates); and rationale if a medium+ potency topical corticosteroid was not appropriate (e.g., intolerance, contraindication, or sensitive area involvement).

Clinical indication and signs/symptoms and evidence of clinical response or need.
Prior treatment history: agents tried, dates, strengths/potency, supply duration (e.g., ≥14 days), and outcomes.
If requesting PA despite no prior medium+ potency topical corticosteroid, provide clear rationale (intolerance, contraindication, or treatment of sensitive areas).
Patient age to determine duration of approval (see DOA rules).

OpenPayer

Pimecrolimus (Elidel) prior authorization

Coverage Criteria

Coding and Fill Rules

Provider Actions and Prior Authorization

Background

Definitions