CurrentConnectiCarePolicy C8268-A

Eucrisa (crisaborole) Coverage for Atopic Dermatitis

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This policy governs prior authorization and coverage requirements for Eucrisa (crisaborole) for atopic dermatitis, including diagnosis, prior topical treatment response or intolerance, baseline disease activity, continuation benefit, and quantity limits.

Policy Summary

PayerConnectiCare

PolicyEucrisa (crisaborole) Coverage for Atopic Dermatitis

Policy CodePolicy C8268-A

Change TypeNo material clinical or coverage changes

Effective DateJun 6, 2026

Next Review DateApr 1, 2027

Key ActionSubmit documentation of the diagnosis, required prior topical treatment history, and baseline disease activity assessment for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial authorization

12 monthsContinuation authorization

85%Continuation adherence

3 months+Minimum age

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CurrentConnectiCarePolicy C8268-A

Eucrisa (crisaborole) Coverage for Atopic Dermatitis

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Policy Summary

PayerConnectiCare

PolicyEucrisa (crisaborole) Coverage for Atopic Dermatitis

Policy CodePolicy C8268-A

Change TypeNo material clinical or coverage changes

Effective DateJun 6, 2026

Next Review DateApr 1, 2027

Key ActionSubmit documentation of the diagnosis, required prior topical treatment history, and baseline disease activity assessment for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial authorization

12 monthsContinuation authorization

85%Continuation adherence

3 months+Minimum age

Standard quantity limit

120 g/30 daysHigher quantity limit

Coverage Criteria

Initial Therapy Criteria

Initial coverage requires ALL of the following:

Initial therapy

Diagnosis: Documented diagnosis of moderate to severe chronic atopic dermatitis (eczema)
Prior topical therapy
- Topical corticosteroids: Inadequate response, serious side effects, or contraindication to topical corticosteroids
- Topical calcineurin inhibitor: Inadequate response, serious side effects, or contraindication to a preferred/formulary topical calcineurin inhibitor such as tacrolimus or pimecrolimus
Baseline assessment: Prescriber documents baseline disease activity assessment, such as affected body surface area, severity of eczematous lesions, or pruritus

Continuation Therapy Criteria

Continuation of therapy requires ALL of the following:

Continuation therapy

Adherence to therapy is at least 85% as verified by the prescriber or medication fill history, OR adherence is below 85% because surgery or treatment of an infection caused a temporary discontinuationAt least 85%
The temporary interruption exception applies only when caused by surgery or treatment of an infection.
Clinical improvement: The member's condition has improved based on the prescriber's assessment of disease control and clinical improvement, such as reduced affected body surface area, improved severity of eczematous lesions, or decreased pruritus severity
Safety: The prescriber attests to, or clinical reviewer finds, no evidence of intolerable adverse effects or drug toxicity

Other uses of Eucrisa (crisaborole) are considered experimental or investigational and follow the applicable off-label policy.

Known hypersensitivity to crisaborole or any component of the formulation is a contraindication to Eucrisa.

Coding and Utilization Parameters

HCPCS CodeHCPCS

Increased Quantity Threshold

Affected body surface area threshold5% or greater

Quantity available at threshold120 g per 30 days

Standard quantity limit60 g per 30 days

Continuation Adherence

Minimum adherenceAt least 85% of the time

VerificationVerified by the prescriber or member medication fill history

Temporary interruption exceptionAdherence below 85% is permitted when surgery or treatment of an infection causes temporary discontinuation

Provider Requirements and Review Risks

Prior Authorization

Prior Authorization Documentation Required

Prior authorization is required. Submit documentation supporting the diagnosis, prior topical treatment history, and baseline disease activity for medical-necessity review.

Document moderate to severe chronic atopic dermatitis (eczema).
Document inadequate response, serious side effects, or contraindication to two required topical therapies.
Include the prescriber's baseline assessment of disease activity.

Billing Rule

Illinois Prior Authorization Duration

For a recurring health care service or maintenance medication used to treat a chronic or long-term condition, an Illinois prior authorization must remain valid for the lesser of 12 months from approval or the length of treatment determined by the patient's health care professional.

Clinical Background

Eucrisa (crisaborole) is a topical phosphodiesterase 4 inhibitor used to treat atopic dermatitis. Its FDA-approved topical indication includes mild to moderate atopic dermatitis in adults and pediatric patients 3 months of age and older. Under this policy, coverage criteria require documentation of moderate to severe chronic atopic dermatitis and prior difficulty with specified topical therapies.

Policy Definitions

Moderate to Severe Chronic Atopic Dermatitis

ConditionChronic eczematous skin condition

Severity required for coverageDocumented as moderate to severe

Coverage contextUsed for purposes of the Eucrisa coverage criteria

Off-Label or Other Use

UseA use of Eucrisa (crisaborole) that is not otherwise covered under the policy

ClassificationExperimental or investigational

Policy handlingFollows the applicable off-label policy

Initial Therapy

Initial Therapy Criteria

Initial therapy requires ALL of the following:

Initial therapy

Diagnosis: Documented diagnosis of moderate to severe chronic atopic dermatitis (eczema)
Prior topical therapy
- Topical corticosteroids: Inadequate response, serious side effects, or contraindication to topical corticosteroids
- Topical calcineurin inhibitor: Inadequate response, serious side effects, or contraindication to a preferred/formulary topical calcineurin inhibitor such as tacrolimus or pimecrolimus

Continuation Therapy

Continuation Therapy Criteria

Continuation of therapy requires ALL of the following:

Continuation therapy

Adherence to therapy is at least 85% as verified by the prescriber or medication fill history, OR adherence is below 85% because surgery or treatment of an infection caused a temporary discontinuationAt least 85%
The temporary interruption exception applies only when caused by surgery or treatment of an infection.
Clinical improvement: The member's condition has improved based on the prescriber's assessment of disease control and clinical improvement, such as reduced affected body surface area, improved severity of eczematous lesions, or decreased pruritus severity
Safety: The prescriber attests to, or clinical reviewer finds, no evidence of intolerable adverse effects or drug toxicity

Required Prior Treatment

Step	Required treatment history	Failure criteria
1	Two of the following: topical corticosteroids or a preferred/formulary topical calcineurin inhibitor, including tacrolimus or pimecrolimus	Inadequate response, serious side effects, or contraindication

Quantity Limits

Eucrisa Quantity Limits

Standard limit60 g per 30 days

Increased limit120 g per 30 days when 5% or greater body surface area is affected

Above maximumMore than 120 g per 30 days requires provider documentation supporting the greater quantity

Site of Care

Billing Rule

Use the recommended site of care

Topical medication is recommended for pharmacy benefit coverage and patient self-administration.

Policy Summary

PayerConnectiCare

PolicyEucrisa (crisaborole) Coverage for Atopic Dermatitis

Policy CodePolicy C8268-A

Change TypeNo material clinical or coverage changes

Effective DateJun 6, 2026

Next Review DateApr 1, 2027

Key ActionSubmit documentation of the diagnosis, required prior topical treatment history, and baseline disease activity assessment for prior authorization.

SourceLink

On This Page

Applies to Illinois Marketplace coverage.
The provision does not require coverage of care or services otherwise completely excluded by the policy, except as required by applicable medical-exception processes.

Documentation Required

Illinois Medical Exception Criteria

For an Illinois off-formulary exception request, do not deny the request when the formulary drug is contraindicated, when the patient tried it and the prescriber submits evidence of failure or intolerance, or when the patient is stable on a provider-selected drug for the condition under a current or previous plan.

If granted, authorize the prescribed covered drug up to the quantity covered under the policy.
A granted medical exception must be honored for 12 months after approval or until plan renewal.

Unsupported block type: step_therapy

Unsupported block type: documentation

Unsupported block type: billing_rule

Documentation Required

Additional Review Documentation

Additional documentation may be required for coverage determination, quality-improvement, and fraud, waste, and abuse review. Provide complete patient-specific evidence, including records, test results, provider credentials, and member-specific measurements when applicable.

Submit patient records and relevant test results.
Provide credentials of the provider ordering or performing the drug or service when requested.
Include weight, body-surface area, or other member-specific measurements when dosing or medical necessity depends on them.

Denial Risk

Diagnosis or Prior-Treatment Criteria Not Met

Coverage may be denied when the documented diagnosis or required prior-treatment criteria are not met.

The diagnosis must be moderate to severe chronic atopic dermatitis (eczema).
Documentation must support inadequate response, serious side effects, or contraindication to two required topical therapies.

Denial Risk

Missing Baseline Disease Assessment

Coverage may be denied when the prescriber does not provide a baseline assessment of disease activity before initial therapy.

Include measurable or clinically described baseline findings, such as affected body-surface area, lesion severity, and pruritus.

Denial Risk

Continuation Criteria Not Met

Continuation coverage may be denied when documentation does not establish required adherence or an allowable interruption, clinical improvement, and tolerability.

Support adherence of at least 85%, or explain temporary discontinuation for surgery or infection.
Document improvement in disease control and clinical findings while on therapy.
Confirm no intolerable adverse effects or drug toxicity.

Denial Risk

Insufficient Support for Excess Quantity

Requests above 120 grams per 30 days may be denied when the provider does not submit documentation supporting the excess quantity.

The standard limit is 60 grams per 30 days, or 120 grams per 30 days when at least 5% of body surface area is affected.
Provide member-specific clinical rationale for approval above 120 grams per 30 days.

Denial Risk

Insufficient or Inappropriate Documentation

Reimbursement may be denied or other action taken when submitted documentation does not support medical necessity, non-investigational status, benefit eligibility, or appropriate billing and utilization.

Maintain patient records, test results, and provider credentials supporting the determination.
Documentation may be reviewed for inappropriate or excessive billing or other practice patterns.

Denial Risk

Experimental or Investigational Use

Uses of Eucrisa (crisaborole) outside the covered policy indications are considered experimental or investigational and are subject to the applicable off-label policy.

The covered indication described in this policy is moderate to severe chronic atopic dermatitis meeting the stated criteria.

Denial Risk

Known Hypersensitivity

Coverage may be denied when the patient has known hypersensitivity to crisaborole or any component of the Eucrisa formulation.

Review the patient's allergy and hypersensitivity history before prescribing.

Baseline assessment: Prescriber documents baseline disease activity assessment, such as affected body surface area, severity of eczematous lesions, or pruritus

Age restriction: Member is 3 months of age or older3 months and older

Age restriction is stated separately from the diagnosis criteria.