CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Eucrisa (crisaborole) — Step Therapy, Quantity Limits, and Prior Authorization Criteria

Defines step therapy, quantity limits, and prior authorization criteria for Eucrisa (crisaborole) for treatment of mild to moderate atopic dermatitis for covered members under the payer's prescription benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEucrisa (crisaborole) — Step Therapy and Prior Authorization (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when initial step therapy criteria are not met or when requesting quantities that exceed the initial quantity limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 gstandard 1-month quantity limit

180 gstandard 3-month quantity limit

120 g1-month >5% BSA

360 g3-month >5% BSA

Initial 3 moduration of approval

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Coverage Criteria for Eucrisa (crisaborole)

Initial Authorization (Atopic Dermatitis)

Authorization may be granted when the requested drug is being prescribed for mild to moderate atopic dermatitis when ALL of the following criteria are met:

age: The patient is 3 months of age or older

special_condition_or_prior_steroid_trial: The patient meets ONE of the following: (1) the patient is less than 2 years of age; (2) the requested drug will be used on sensitive skin areas (e.g., face, genitals, or skin folds); (3) the patient experienced an inadequate treatment response to a medium or higher potency topical corticosteroid; (4) the patient experienced an intolerance to a medium or higher potency topical corticosteroid; (5) the patient has a contraindication that would prohibit a trial of a medium or higher potency topical corticosteroid

quantity_BSA: If additional quantities are being requested, then 5 percent or greater body surface area is affected>=5% BSA

Continuation/Repeat Authorization

Authorization may be granted for continuation when ALL of the following are met:

age: The patient is 3 months of age or older

clinical_response: The patient has achieved or maintained a positive clinical response as evidenced by improvement or resolution of signs or symptoms (e.g., erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, OR pruritus)

quantity_BSA: If additional quantities are being requested, then 5 percent or greater body surface area is affected>=5% BSA

Initial step therapy requires that the member have filled a prescription for at least a one‑day supply of a medium or higher potency topical corticosteroid within the past 180 days under the prescription benefit administered by CVS Caremark. If that step is met at point of sale, the claim will process and the applicable quantity limit will apply (standard limits shown below). If the member does not meet the initial step therapy requirement, the claim will reject with a message that a prior authorization (PA) is required and the PA criteria will be applied to any submitted requests. Additionally, if the requested quantity exceeds the applicable initial quantity limit at point of sale, the claim will reject and indicate that a PA is required for larger quantities.

Authorization is limited to use for mild to moderate atopic dermatitis in members who meet the listed clinical criteria (including age ≥ 3 months and one of the special conditions or documented corticosteroid trial outcomes). Requests that do not document the required age or clinical criteria will not meet the coverage criteria and therefore authorization will be denied. If the initial step therapy criteria are not met at the point of sale, the claim will reject and a PA is required for further consideration; absence of supporting documentation when a PA is submitted (for example, lack of documentation showing inadequate response/intolerance/contraindication to a medium or higher potency topical corticosteroid when that is the rationale) may result in denial.

Body Surface Area and Quantity Coding

Body Surface Area (BSA) — Thresholds and quantity limits

BSA threshold for additional quantities>= 5% body surface area (BSA) required when requesting quantities above the standard limit

Standard 25-day quantity limit60 grams per 25 days (standard 30-day fill period)

Standard 75-day quantity limit180 grams per 75 days (standard 90-day fill period)

Quantity limit when >=5% BSA affected (25 days)120 grams per 25 days

Quantity limit when >=5% BSA affected (75 days)360 grams per 75 days

Provider Actions, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

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

Initial step therapy requires the patient have filled a prescription for at least a one day supply of a medium or higher potency topical corticosteroid within the past 180 days.
If the patient meets the initial step therapy criteria, a quantity limit will apply. If the patient is requesting more than the initial quantity limit at the point of sale, the claim will reject with a message indicating that a PA is required.

Step Therapy

Initial Step Therapy Requirement

Initial step therapy must be documented: the member must have filled a prescription for at least a one day supply of a medium or higher potency topical corticosteroid within the past 180 days. Claims will be rejected at point of sale when this initial step therapy criterion is not met.

Definitions

Eucrisa (crisaborole) — Definition and indication

IndicationTopical treatment indicated for mild to moderate atopic dermatitis in patients aged 3 months and older

FDA age cut-offApproved for use in adult and pediatric patients 3 months of age and older

Policy positioningEucrisa is used for mild to moderate atopic dermatitis and may be authorized per criteria when step-therapy conditions or special circumstances apply

Medium or higher potency topical corticosteroid — Examples and relevance

DefinitionMedium or higher potency topical corticosteroids — includes named examples spanning medium, high, and very high potency agents

Example agents (medium potency and above)Examples listed include betamethasone dipropionate, betamethasone valerate, clocortolone pivalate, desonide, desoximetasone, fluocinolone, flurandrenolide, fluticasone, hydrocortisone butyrate, hydrocortisone probutate, mometasone, prednicarbate, triamcinolone, amcinonide, diflorasone, halcinonide, fluocinonide, and others

Background

Eucrisa (crisaborole) is a topical, nonsteroidal phosphodiesterase‑4 (PDE4) inhibitor FDA‑approved for the treatment of mild to moderate atopic dermatitis in patients aged 3 months and older. Within this policy, Eucrisa is positioned as a therapy appropriate when members meet the clinical criteria listed (including situations where medium or higher potency topical corticosteroids are unsuitable such as use on sensitive areas, age <2 years, intolerance, or contraindication) or when a documented inadequate response to such corticosteroids has occurred.