Crisaborole (Eucrisa) topical therapy — Coverage Criteria
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Defines medical necessity criteria, prior authorization and continuation requirements for crisaborole (Eucrisa) topical treatment of mild to moderate atopic dermatitis for Delaware First Health members under the referenced policy.
No material clinical or coverage changes in this revision.
Coverage Criteria for Crisaborole (Eucrisa)
inv-01: Initial Approval — Atopic Dermatitis
Covered when ALL of the following are met:
Approval duration: 6 months
inv-02: Continued Therapy — Atopic Dermatitis
Covered when ALL of the following are met:
Approval duration: 12 months
inv-03: Other Diagnoses/Indications
When requested use is not listed in main coverage or policy is outdated:
inv-05: Initial coverage criteria
Covered when ALL of the following are met
Supported by dosing guidance
Product dosing: apply to affected areas twice daily; product available in 60 g or 100 g
Hypersensitivity listed as contraindication
Non‑FDA approved indications that are not addressed in this policy are not authorized unless there is sufficient documentation of efficacy and safety consistent with the plan's off‑label use procedures (see off‑label use policy CP.PMN.53) or applicable evidence of coverage documents.
The document fragments include extensive listings of topical corticosteroid products and formulations (multiple agents and potencies are cited across the extracted text), but these excerpts do not identify any explicit exclusions specific to crisaborole.
The visible policy excerpts do not state any explicit coverage exclusions in the provided portions; the text is primarily a fragmented list of topical corticosteroid agents, formulations and dosing notations.
No exclusionary conditions for crisaborole are specified in these chunks; the content consists of topical corticosteroid product and formulation listings without stated exclusions for crisaborole.
Within the provided excerpts there are no explicit coverage exclusions identified for crisaborole; the material is limited to enumerating alternative topical corticosteroid agents and formulations.
These document fragments do not include explicit coverage exclusions for crisaborole; instead they list numerous topical corticosteroid comparators (various potencies and formulations) without declaring crisaborole ineligible under specific conditions.
No explicit coverage exclusions for crisaborole are present in the visible text. The excerpts primarily contain medium‑ and high‑potency topical corticosteroid listings and application notes rather than policy exclusion language.
The chunks provided do not articulate any explicit exclusions for crisaborole; they repeat lists of topical corticosteroid products (including multiple medium‑potency agents) without stating crisaborole is excluded under particular circumstances.
Use of crisaborole is contraindicated in patients with a known hypersensitivity to crisaborole or to any component of the formulation.
No statements in the provided excerpts explicitly label any therapy as 'not medically necessary.' The visible text focuses on listing topical corticosteroid agents and related dosing information rather than declaring therapies medically unnecessary.
In the segments available there are no explicit 'not medically necessary' declarations. The content largely enumerates comparator topical corticosteroids and application instructions without NMN determinations.
No portions of the provided text explicitly state that any listed therapy is 'not medically necessary.' The excerpts are limited to product lists and do not include NMN language for crisaborole or comparators.
The document fragments do not contain explicit 'not medically necessary' statements; they are focused on topical corticosteroid product listings and dosing notes rather than NMN policy language.
No additional 'not medically necessary' statements are evident in these excerpts. The visible content repeats topical corticosteroid names and formulations without NMN determinations.
Coding and Quantity Limits
| N/A | No explicit procedure or billing codes listed in this excerpt |
Provider Actions, Prior Authorization, and Documentation
Prior authorization required; electronic approval after required trials
Eucrisa will be electronically approved after trial of a preferred topical steroid or immunomodulator; prior authorization requires documentation of trials per the initial approval criteria (including failure of required topical corticosteroid trials and, for age ≥2 years, tacrolimus trials unless contraindicated).
- Electronic approval follows documented trials of preferred topical steroid or immunomodulator.
- Documentation must demonstrate trials described in the Initial Approval Criteria (2-week trials of topical corticosteroids; for ≥2 years, 2-week trial of topical tacrolimus when applicable).
No explicit prior authorization statement in this segment
The provided excerpts in these chunks do not contain an explicit prior authorization requirement for crisaborole nor do they list affected billing codes.
Prior authorization not specified in this section
No explicit prior authorization requirements are stated in this section of the document fragments.
Prior authorization not specified in excerpt
This excerpt primarily lists topical corticosteroids and does not state explicit prior authorization requirements for crisaborole.
No prior authorization specified for product listings
Product listings and brand names are provided in this excerpt, but no prior authorization requirements for crisaborole or listed topical agents are specified.
Prior authorization not specified in this fragment
This fragment does not contain explicit prior authorization instructions for crisaborole.
No prior authorization instructions included
No prior authorization instructions or affected billing codes are included in this excerpt.
Prior authorization not specified for medium‑potency listings
This excerpt lists medium‑potency topical corticosteroids and formulations but does not state prior authorization requirements for crisaborole.
No prior authorization specified in this section
This section enumerates medium‑potency topical corticosteroids and does not specify prior authorization requirements for crisaborole or the listed corticosteroids.
Prior authorization not specified in excerpt
This fragment does not state explicit prior authorization requirements for crisaborole (Eucrisa) or related products.
Plan procedures may require prior authorization
Coverage decisions are subject to plan terms and may require prior authorization per Health Plan procedures; state Medicaid provisions take precedence when conflicting.
- Refer to applicable Health Plan administrative policies for prior authorization requirements.
- For Medicaid members, state Medicaid coverage provisions override conflicting policy language.
Step therapy: documented trials of topical corticosteroids (and tacrolimus when applicable)
Initial therapy requires documented failure of a 2‑week trial of two generic or one preferred medium‑ to very‑high‑potency topical corticosteroids of different molecular identities; for patients ≥2 years, failure of a 2‑week trial of topical tacrolimus is also required unless contraindicated.
- 2-week trial of two generic or one preferred medium to very high potency topical corticosteroids of different molecular identities, unless contraindicated.
- For age ≥2 years: failure of a 2-week trial of topical tacrolimus, unless contraindicated.
High‑potency corticosteroids listed; no explicit step sequence
The document lists many high‑potency topical corticosteroids and formulations, but these chunks do not state an explicit step‑therapy order or required trials before crisaborole.
Topical corticosteroids listing with BID application
Multiple high‑potency topical corticosteroids are listed with the application instruction to apply topically to the affected area(s) twice daily for listed agents.
- Apply topically to the affected area(s) BID for several listed topical corticosteroids.
Alternatives listed; sequencing not defined
The text presents alternative topical corticosteroids across potencies and formulations that may be considered therapeutic alternatives, but it does not define an explicit sequencing for step therapy in these chunks.
No step therapy sequences specified in these chunks
No formal step‑therapy sequences or fail‑first requirements are defined in the provided document fragments.
Comparator corticosteroids listed; no mandatory sequencing
The fragments list numerous topical corticosteroids as comparators or formulary alternatives, but they do not define mandatory step‑therapy rules in this excerpt.
No step therapy requirements in this document portion
No step therapy requirements are stated in this portion of the document.
No fail‑first sequences defined here
The provided excerpt does not define any fail‑first or step‑therapy sequences; only comparator agents and alternatives are enumerated.
Therapeutic alternatives listed; no formal step algorithm
No step therapy or fail‑first sequences are defined in the provided text; topical corticosteroids and calcineurin inhibitors are listed as therapeutic alternatives to consider.
- Therapeutic alternatives include topical corticosteroids and topical calcineurin inhibitors (e.g., tacrolimus).
Required documentation to support approval
Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria; failure to provide supporting documentation may trigger denial.
- Submit office chart notes or other clinical information demonstrating trials and medical necessity per the Initial Approval Criteria.
- Insufficient documentation may result in claim or authorization denial.
Dosing instructions noted; not a documentation requirement
The provided text contains dosing instructions for listed topical corticosteroids, e.g., 'Apply topically to the affected area(s) BID', but these dosing instructions are not specified as documentation requirements for crisaborole prior authorization.
- Dosing note: many listed topical corticosteroids include 'Apply topically to the affected area(s) BID'.
No other specific documentation requirements stated
No additional specific documentation requirements (such as required forms or discrete lab values) are specified in these chunks beyond general clinical documentation supporting that the member meets approval criteria.
No explicit submission form requirements in these excerpts
No clear documentation or submission requirements (e.g., formal prior authorization form fields) are specified in these fragments.
No documentation requirements in this excerpt
No documentation requirements are specified in this excerpt.
Documentation not specified in this fragment
No documentation requirements or instructions are included in this fragment of the policy.
Topical application: apply to affected areas BID
Apply crisaborole 2% ointment (and listed topical corticosteroids) topically to the affected area(s) twice daily as documented in dosing guidance for mild‑to‑moderate atopic dermatitis.
- Instruction appearing for multiple agents: 'Apply topically to the affected area(s) BID.'
- Crisaborole dosing: crisaborole 2% ointment applied twice daily for mild‑to‑moderate atopic dermatitis.
Follow Health Plan administrative policies; document medical necessity
Providers should follow Health Plan administrative policies and coverage document terms; documentation submitted should support medical necessity per this clinical policy and applicable state Medicaid provisions.
Denial risk: insufficient supporting documentation
Failure to provide supporting documentation (e.g., office chart notes, lab results, or other clinical information) demonstrating the member meets approval criteria may result in denial of the request.
No other explicit denial triggers in these fragments
No explicit denial triggers (beyond failure to provide supporting documentation or contraindication) are present in the provided text; many chunks list topical corticosteroid products without stating authorization or denial rules.
Denial risk: hypersensitivity contraindication
Claims may be denied for members with hypersensitivity to crisaborole or any component of the formulation; hypersensitivity is listed as a contraindication.
- Contraindication: hypersensitivity to crisaborole or any component of the formulation.
Denial risk: missing supporting documentation
Failure to provide required supporting documentation demonstrating that the member meets approval criteria may trigger denial (duplicate of the primary documentation/denial risk statement).
Background
Crisaborole (Eucrisa) is a topical phosphodiesterase‑4 inhibitor approved by the FDA for treatment of mild to moderate atopic dermatitis in patients aged ≥3 months. The policy defines medical necessity criteria, prior authorization and continuation requirements for crisaborole and instructs providers to follow Health Plan administrative policies; documentation should support medical necessity per this clinical policy and applicable state Medicaid provisions.
Definitions and Key Terms
Revision History
Policy effective date established as 09.25 (2025-09-25).
Policy created with initial documentation and P&T approval noted in May 2025.
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