Pimecrolimus (Elidel) And Tacrolimus (Protopic) - Medical Necessity Request Form printable pdf download

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

Horizon NJ Health

Pimecrolimus (Elidel) and Tacrolimus (Protopic) – Medical Necessity Request

1. What is/are the affected area(s)? _______________________________________________________________

2. Is the member immunocompromised? Yes or No

If Yes, please provide the diagnosis or treatment that causes the member to be immunocompromised.

_________________________________________________________________________________

3. Has the member tried and failed a topical corticosteroid (e.g., OTC hydrocortisone, hydrocortisone valerate,

betamethasone, fluocinolone, mometasone, fluticasone, desoximetasone)? Yes or No

If No, can the patient try a topical corticosteroid instead of Elidel/Protopic? Yes or No

- If Yes, please call the prescription in to the pharmacy.

- If No, please provide the clinical reason(s) why the member cannot try a topical corticosteroid first.

________________________________________________________________________________

4. For Elidel requests: Can patient try Tacrolimus Ointment? Yes or No

- If Yes, please call the prescription in to the pharmacy.

- If No, please provide the clinical reason(s) why the member cannot try Tacrolimus Ointment.

________________________________________________________________________________

Diagnosis Information (please indicate diagnosis and answer related questions):

□ Atopic Dermatitis/Eczema

□ Dermatitis

- What type of dermatitis does the member have?

□ Atopic

□ Other: _______________________________________________

□ Psoriasis

□ Inverse/Intertriginous Psoriasis

□ Facial Psoriasis

□ Other: ___________________________________

Complete this section only for members less than 2 years of age:

1. Is the condition poorly controlled? Yes or No

2. Is the condition persistent? Yes or No

3. Is the member being managed by an Allergist or Dermatologist? Yes or No

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office

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Rev. 03/16

HNJH Fax #: 888-567-0681

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Pimecrolimus (Elidel) And Tacrolimus (Protopic) - Medical Necessity Request Form