CurrentBlue Cross Blue Shield - IowaPolicy 05.02.51

Eucrisa (crisaborole) topical ointment — coverage criteria

Covers criteria for Wellmark/Blue Cross Blue Shield - Iowa members for initial and continuation coverage of Eucrisa (crisaborole) topical ointment for mild to moderate atopic dermatitis in patients aged 3 months and older.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyEucrisa (crisaborole) topical ointment — coverage criteria

Policy CodePolicy 05.02.51

Change TypeNo material changes

Effective DateJun 20, 2020

Next Review DateAug 1, 2025

Key ActionObtain prior authorization with documentation that the patient is ≥3 months old and meets the listed initial or continuation criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsminimum patient age for coverage

60 g/30dstandard quantity limit

120 g/30dquantity limit if ≥5% BSA

12 moapproval duration (continuation)

Coverage Criteria

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Initial Therapy

Covered when ALL of the following are met:

Initial approval main criteria: Patient is 3 months of age or older and the requested drug is prescribed for mild to moderate atopic dermatitis

based on FDA indication

Special pediatric/sensitive-area pathway: For patients less than 2 years of age or when treating sensitive skin areas (face, genitals, or skin folds), Eucrisa may be considered medically necessary when there is inadequate treatment response, intolerance, or contraindication to a topical calcineurin inhibitor (and, when required, also to a medium or higher potency topical corticosteroid)

Approval for this pathway will be for 3 months; quantity limits apply (60 g/30 days or 120 g/30 days if ≥5% BSA)

Continuation Therapy

Covered for continuation when ALL of the following are met:

Continuation criteria: Requested drug is for continuation and the patient achieved or maintained a positive clinical response as evidenced by improvement in signs or symptoms (e.g., erythema, edema, xerosis, erosions, excoriation, oozing/crusting, lichenification, or pruritus)

Approval duration 12 months; quantity limits apply (60 g/30 days or 120 g/30 days if ≥5% BSA)

Benefit determinations are based on the applicable contract language in effect at the time services were rendered. Exclusions, limitations, or exceptions may apply and benefits can vary by contract; individual member benefits must be verified prior to authorization.

This policy may not apply to Federal Employee Program (FEP) members. Wellmark/Blue Cross Blue Shield — Iowa determines medical necessity only if the benefit exists and no contract exclusions are applicable; FEP benefit determinations are made by the Federal Employee Program.

Use of Eucrisa in patients younger than 3 months of age is not within the FDA‑approved indication and would be considered not medically necessary under this policy unless otherwise supported by contract language or compendia.

When applicable (for example, patients younger than 2 years or treatment of sensitive skin areas such as face, genitals, or skin folds), documentation must show prior therapy trials or documented intolerance/contraindication to a topical calcineurin inhibitor (and when required, a medium or higher potency topical corticosteroid) before Eucrisa will be considered.

Coding and Quantity Limits

Procedures and billing codes (general instruction)mixed

not specified

Policy references use of appropriate CPT, HCPCS, Revenue, and ICD diagnostic codes but does not list specific codes.

Body surface area threshold and quantity limits

Standard quantity limit60 gm per 30 days

Increased quantity when BSA threshold met>= 5% body surface area affected — 120 gm per 30 days

BSA threshold definition>= 5% body surface area affected

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must document the patient is at least 3 months of age and that initial-therapy criteria are met before approval is granted.

Applies to initial requests for Eucrisa (crisaborole).
Approval for initial therapy: 3 months; quantity limit 60 gm per 30 days (120 gm per 30 days if ≥5% BSA involved).

Step Therapy

Step Therapy Prerequisites

Step therapy prerequisites for certain patients. For patients <2 years of age or when treating sensitive skin areas (face, genitals, skin folds), documentation must show prior inadequate response, intolerance, or contraindication to a topical calcineurin inhibitor. In some cases, lack of response to both a topical calcineurin inhibitor and a medium-or-higher potency topical corticosteroid must be documented.

Patients <2 years or when drug will be used on sensitive areas: trial of topical calcineurin inhibitor required unless contraindicated/intolerant.
If applicable, documentation of inadequate response or intolerance to both topical calcineurin inhibitor and medium/higher potency topical corticosteroid is required.

Documentation Required

Documentation for Continuation of Therapy

Continuation documentation required. For renewal requests, provide documentation that the patient achieved or maintained a positive clinical response — e.g., improvement or resolution of signs/symptoms such as erythema, edema, xerosis, erosions, excoriation, oozing/crusting, lichenification, or pruritus.

Continuation approvals: 12 months; quantity limit 60 gm per 30 days (120 gm per 30 days if ≥5% BSA involved).
Clinical notes should describe the specific signs/symptoms improved or maintained.

Denial Risk

Denial Triggers / Risk Conditions

Denial triggers — watch for these to avoid delays or denials. Requests lacking required prior-therapy documentation, those for patients younger than 3 months, or missing documentation of clinical response for continuation are subject to denial.

Patient age <3 months at time of request — deny.
Missing documentation of required prior trials (e.g., topical calcineurin inhibitor) when applicable — deny.
Insufficient evidence of positive clinical response for continuation — deny.

Background

Crisaborole (Eucrisa) is a topical, nonsteroidal phosphodiesterase‑4 (PDE4) inhibitor indicated for the topical treatment of mild to moderate atopic dermatitis in patients 3 months of age and older.

The policy aligns coverage with the FDA‑approved indication for Eucrisa and considers its use medically necessary when the stated age and prior‑therapy criteria are met.