CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Eucrisa (crisaborole) step therapy and quantity limits

CVS Caremark-administered step therapy and post-step prior authorization policy for Eucrisa (crisaborole) under the prescription benefit, specifying initial step requirements, quantity limits for initial and refill periods, and clinical criteria for atopic dermatitis in patients ≥3 months.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEucrisa (crisaborole) step therapy and quantity limits

Policy CodePolicy N/A

Change Typeclarified (non-material)

Effective Date

Next Review Date

Key ActionIf patient does not meet initial step therapy criteria the claim will reject and a prior authorization (PA) must be submitted to the PA unit for evaluation.

POLICY UPDATE CHANGES

Policy aligns CVS Caremark step therapy limits with specified gram-per-period limits (60 g/25 days; 180 g/75 days) and higher limits for >5% BSA.

3Age categories referenced (>=3 months, <2 years special rule)

2Initial quantity options (30-day and 90-day equivalencies)

5%BSA threshold for additional quantities

Coverage Summary

CVS Caremark covers Eucrisa (crisaborole) with clinical criteria: it is available under a step therapy pathway for patients 3 months and older. The policy requires meeting initial step therapy criteria (trial/consideration of a medium or higher potency topical corticosteroid or qualifying special circumstances such as use on sensitive areas or age-based considerations) and applies quantity limits to approved fills. Continuation/maintenance coverage requires documentation of a positive clinical response and meeting quantity/BSA rules. The program is administered by CVS Caremark and includes prior authorization when initial step criteria or quantity limits are not met.

Initial Step Therapy with Quantity Limit (Eucrisa)

Include Rx and OTC products unless otherwise stated. If patient meets initial step therapy criteria a quantity limit applies. If patient does not meet initial step therapy criteria, claim will reject and prior authorization is required.

ALL of the following

Patient is 3 months of age or older>= 3 months
Patient meets ONE of the following
- Requested medication will be used on sensitive skin areas (face, genitals, or skin folds)
- Patient is less than 2 years of age< 2 years
- Patient experienced an inadequate treatment response to a medium or higher potency topical corticosteroid
- Patient has a contraindication that would prohibit a trial of a medium or higher potency topical corticosteroid
- Patient experienced an intolerance to a medium or higher potency topical corticosteroid
If additional quantities are requested, then >= 5 percent body surface area (BSA) is affected>= 5% BSA

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Step Therapy

Step therapy requirement

CVS Caremark requires step therapy for Eucrisa. Both prescription and over‑the‑counter (OTC) products are included. If the patient does not meet the initial step therapy criteria the claim will reject and prior authorization (PA) is required. When the patient meets the initial step criteria, a quantity limit applies.

Initial quantity limits: 60 grams per 25 days (30‑day fill equivalent); 180 grams per 75 days (90‑day fill equivalent)
If ≥5% body surface area (BSA) affected, higher limits apply: 120 grams per 25 days; 360 grams per 75 days

Post Step Therapy Prior Authorization / Continuation

Documentation Required

Clinical response documentation for continuation

When requesting a continuation PA, document that the patient has achieved or maintained a positive clinical response. Specifically document improvement in or resolution of any of the following signs/symptoms and report BSA when requesting additional quantity: erythema (redness), edema (swelling), xerosis (dry skin), erosions, excoriations (evidence of scratching), oozing/crusting, lichenification (epidermal thickening), or pruritus (itching).

Erythema (redness)
Edema (swelling)
Xerosis (dry skin)
Erosions
Excoriations (evidence of scratching)
Oozing and crusting
Lichenification (epidermal thickening)
Pruritus (itching)

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required if initial step criteria not met

If the patient does not meet the initial step therapy criteria the claim will reject with a message indicating a prior authorization (PA) is required; requests must be submitted to the PA unit for evaluation.

Includes both prescription (Rx) and over‑the‑counter (OTC) products unless otherwise stated

Prior Authorization

Prior authorization required for quantities above limit

A prior authorization is required for quantities above the initial limit. The policy sets initial quantity limits at 60 grams per 25 days and 180 grams per 75 days; for patients with ≥5% BSA affected, higher limits apply at 120 grams per 25 days and 360 grams per 75 days. Claims exceeding these limits will reject and require PA.

60 grams per 25 days (initial month limit)
180 grams per 75 days (initial 3‑month limit)
120 grams per 25 days when ≥5% BSA affected
360 grams per 75 days when ≥5% BSA affected

Clinical Evidence & References

Key evidence and references cited in the policy include the FDA Eucrisa package insert (Pfizer, April 2023) and guideline and trial literature: Paller AS et al. (J Am Acad Dermatol. 2016) and atopic dermatitis topical therapy guidelines (Eichenfield et al. 2014; Eichenfield/Sidbury et al. 2023). Point-of-care resources cited include Lexicomp and Micromedex. The evidence base supports FDA approval of Eucrisa for topical treatment of mild-to-moderate atopic dermatitis in patients 3 months and older.

Background

Eucrisa (crisaborole) is FDA-approved for topical treatment of mild-to-moderate atopic dermatitis in patients 3 months of age and older. The CVS Caremark policy implements an initial step therapy pathway that generally requires a trial or consideration of a medium or higher potency topical corticosteroid before Eucrisa will process without prior authorization, while allowing exceptions for use on sensitive areas (face, genitals, skin folds) and for young children. Quantity limits are applied to approved fills: the initial limits are 60 grams per 25 days (used for a 30-day fill) and 180 grams per 75 days (used for a 90-day fill); higher limits apply when ≥ 5 percent body surface area is affected (120 grams per 25 days or 360 grams per 75 days). Continuation prior authorization requires documentation of a positive clinical response and BSA if requesting additional quantity.

Definitions

Initial Step TherapyRequirement to try specified therapies (including Rx and OTC) within prior 180 days under CVS Caremark benefit before Eucrisa will be processed without PA.

Quantity limit month/3-monthSpecified gram limits apply per 25-day (used for 30-day fill) and 75-day (used for 90-day fill) periods to allow refill processing (e.g., 60 g/25 days and 180 g/75 days; higher limits for >5% BSA).