CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization for Eucrisa (crisaborole) for atopic dermatitis

This document is a Washington prior authorization request form used by Colorado Rocky Mountain Health Plans for requests of Eucrisa (crisaborole) for treatment of atopic dermatitis; it guides providers on information and clinical criteria required for PA determination.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization for Eucrisa (crisaborole) for atopic dermatitis

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Washington Prior Authorization Request Form for Eucrisa with required documentation and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursminimum review turnaround time requested

>=2required trials of preferred topical corticosteroids

>=28 daysminimum duration for steroid or calcineurin inhibitor trial

1required trial of topical calcineurin inhibitor

Coverage Criteria for Eucrisa (crisaborole)

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Authorization criteria for Eucrisa

Covered when ALL of the following are documented:

Main criteria: 1) A completed prior authorization form with member and provider information, a specific diagnosis with ICD-10 code, prescriber signature and specialty, and baseline evaluation/chart notes documenting disease severity.

Use Section C for diagnosis and ICD-10; include baseline evaluation and chart notes as required.

New request - topical steroid trials: 2) For new requests: documentation of trial and failure of at least TWO preferred topical corticosteroids (medium or higher potency) used daily for a minimum of 28 days within the previous 6 months OR documentation of an accepted exemption.>= 2 within previous 6 months; >= 28 days each

Record specific products, directions, dates of therapy, and reasons for failure in Section D; acceptable exemptions include steroid contraindication, affected sensitive areas not responding to low-potency steroid, steroid-induced atrophy, or long-term uninterrupted prior steroid use.

Topical calcineurin inhibitor trial: 3) Documentation of trial and failure of at least ONE topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) administered for at least 28 days, unless a contraindication applies or the patient is under 2 years old.>= 1; >= 28 days

Document product, dates, directions, and reason for failure in Section D; check contraindication or age exemption as applicable.

Continuation requests: 4) For continuation requests: documentation of disease stability or improvement from baseline must be provided.

Indicate continuation on the form and include documentation of response to therapy.

Topical calcineurin inhibitors are addressed as part of the step therapy requirements for Eucrisa (crisaborole). The form requires documentation that the patient has tried and failed at least one topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) for at least 28 days, unless a contraindication applies. The form explicitly lists patient age less than 2 years as a condition in which topical calcineurin inhibitors may be considered not applicable for the step requirement.

Providers must include a completed PA form with required supporting documentation. The form specifies that a baseline evaluation of disease state including severity and chart notes must be submitted, and the request must include the prescriber signature, prescriber specialty, and the date. Requests missing these items, or lacking documentation of required prior medication trials, may be delayed or denied.

Diagnosis, Trials, and Key Coding Details

Diagnosis codes (to be provided)ICD-10

ICD-10

ICD-10 CODE (provider to specify)

inv-05: Minimum trial duration

Minimum trial duration>= 28 days

ContextMinimum duration applies to both preferred topical corticosteroid and topical calcineurin inhibitor trials as specified on the PA form

Evidence requiredDates of therapy must be listed in Section D of the form to demonstrate the >= 28 day trial

inv-06: Number of preferred topical steroid trials

Number of preferred topical steroid trials>= 2 within previous 6 months

Potency requirementMedium or higher potency topical corticosteroids required for the two trials

ExceptionsMay be exempt if topical steroids contraindicated, sensitive area involvement not responding to low-potency steroids, steroid-induced atrophy, or long-term uninterrupted use

inv-07: Number of topical calcineurin inhibitor trials

Number of topical calcineurin inhibitor trials>= 1

Minimum duration>= 28 days unless contraindicated or patient < 2 years old

ExamplesIncludes agents such as pimecrolimus or tacrolimus as listed on the form

Submission, Documentation, and Prior Authorization Actions

Prior Authorization

Submission and review

Prior authorization is required. Complete the Washington Prior Authorization Request Form in full and fax to 866-940-7328. Allow at least 24 hours for review. If you have questions, call 800-310-6826. Include the member's diagnosis with ICD-10 code and complete Section C (medical information) and Section D (previous medication trials).

Use the Washington Prior Authorization Request Form (complete all pages).
Fax completed form to 866-940-7328.
Allow at least 24 hours for review.
Include prescriber signature, specialty, and date.
Provide baseline evaluation of disease severity and chart notes.

Denial Risk

Triggers for denial or delay

Requests may be denied or delayed if required fields or documentation are missing. Ensure the form is complete and all required supporting documentation is attached to avoid processing delays.

Incomplete or unsigned prior authorization form.
Missing baseline evaluation of disease severity and chart notes.
Missing prescriber diagnosis with ICD-10 code.
Missing documentation of required prior medication trials (see criteria for trials of topical corticosteroids and topical calcineurin inhibitors).
Failure to document trial and failure of at least two preferred medium-or-higher potency topical corticosteroids (28 days each within previous 6 months) when applicable.
Failure to document trial and failure of at least one topical calcineurin inhibitor for at least 28 days when applicable.

Background

Atopic dermatitis is a chronic inflammatory skin disease for which topical anti-inflammatory therapies are standard initial treatment. The Washington prior authorization form for Eucrisa (crisaborole) frames Eucrisa as a non-steroidal topical option to be considered after documentation of prior therapies: the form asks whether the request is for continuation and requests documentation of disease stability or improvement from baseline, and it requires prior trials of topical corticosteroids and topical calcineurin inhibitors (with listed exceptions) before authorizing Eucrisa.

OpenPayer

Prior authorization for Eucrisa (crisaborole) for atopic dermatitis

Coverage Criteria for Eucrisa (crisaborole)

Diagnosis, Trials, and Key Coding Details

Submission, Documentation, and Prior Authorization Actions

Background

Definitions and Continuation