| Anthem Blue Cross (HMO, PPO, EPO) |
| Elidel (pimecrolimus) |
| Drugs for the Skin : Drugs for the Skin |
- Quantity Limit: 100 grams per 30 day(s).
- Step Therapy: Atopic Dermatitis (Eczema):
ST Multiple Generics
- Prior Authorization: Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 year(s)
- Atopic Dermatitis (Eczema):
Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: N/A
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