Limited coverage criteria – pimecrolimus

Last updated on March 20, 2025

Special Authority requests can now be submitted online. It's simple and quick!

Generic name		pimecrolimus
Strength & form		any strength cream

Special Authority criteria	Approval period
Diagnosis of eczema AND Special Authority request is submitted by a dermatologist¹ PLUS one of the following: Patient is refractory to 3 months of specified potent topical corticosteroid therapy² OR Patient is intolerant to specified topical corticosteroid treatment	Indefinite

Special Authority criteria

Approval period

Diagnosis of eczema

AND

Special Authority request is submitted by a dermatologist¹

PLUS one of the following:

Patient is refractory to 3 months of specified potent topical corticosteroid therapy²

Patient is intolerant to specified topical corticosteroid treatment

Indefinite

Practitioner exemptions

None

Special notes

¹The SA request should be submitted by a dermatologist
²Potent corticosteroid medication to be specified in request

Special Authority request form(s)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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