CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Eucrisa (crisaborole) step therapy and quantity limits

Defines initial step therapy, prior authorization, and quantity limit criteria for Eucrisa (crisaborole) topical treatment of mild to moderate atopic dermatitis for affected members and prescribing providers under the payer's pharmacy benefit administered by CVS Caremark.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEucrisa (crisaborole) step therapy and quantity limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when prescribing Eucrisa and document clinical response or >5% BSA when requesting additional quantities.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 gstandard month limit

180 gstandard 3-month limit

120 g>5% BSA month limit

360 g>5% BSA 3-month limit

>=3 mominimum age

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Coverage Criteria for Eucrisa (crisaborole)

Initial and continuation coverage criteria

Covered with prior authorization when ALL of the following are met:

Primary coverage conditions: The requested drug is being prescribed for mild to moderate atopic dermatitis AND the patient is 3 months of age or older

Continuation or initial request: Either the request is NOT for continuation of therapy OR (if continuation) documentation of maintained or improved clinical response is provided

For continuation: documentation of achieved or maintained positive clinical response (improvement or resolution in signs/symptoms such as erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus) is required.

Patients younger than 2 years or special circumstances: If the patient is <2 years of age, one of the following must apply: inadequate response to a medium or higher potency topical corticosteroid, intolerance to a medium or higher potency topical corticosteroid, or contraindication to a medium or higher potency topical corticosteroid

Quantity/BSA requirement for additional quantities: If additional quantities are being requested, then >5% body surface area must be affected>5% BSA

Quantity limits: 60 g per 25 days (standard) or 180 g per 75 days; when >5% BSA affected: 120 g per 25 days or 360 g per 75 days.

Requests for patients younger than 3 months fall outside the FDA-approved age indication for Eucrisa and are therefore not covered under these criteria.

Use of Eucrisa without meeting the initial step therapy requirements or without obtaining the required prior authorization is not approved and will result in claim rejection with an electronic message indicating that a prior authorization is required.

Quantity Limits and BSA-based Adjustments

Body Surface Area (BSA)

ThresholdGreater than 5% body surface area (BSA) affected to qualify for increased quantity limits

ApplicationRequired when additional quantities are requested beyond standard limits

DocumentationProvider must document percent BSA affected when requesting increased quantities

Quantity limits

Standard month limit60 grams per 25 days

Standard 3-month limit180 grams per 75 days

Increased month limit when >5% BSA

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required when coverage criteria are met or when step-therapy or quantity limits are exceeded. If the patient does not meet the initial step therapy criteria, the claim will reject with a message indicating that prior authorization (PA) is required; requests submitted to the PA unit will be evaluated against the authorization criteria.

Applies when the requested drug is prescribed for mild to moderate atopic dermatitis and other coverage criteria are met
Claims will reject with a PA-required message if initial step therapy criteria are not met or if requested quantity exceeds initial limits

Step Therapy

Initial Step Therapy with Quantity Limit

An initial step therapy requirement applies. If the patient has not met the initial step therapy (e.g., prior use of required Rx/OTC agents within the past 180 days under the prescription benefit administered by CVS Caremark), the claim will reject and a PA will be required. When initial step therapy criteria are met, an initial quantity limit applies; requests for more than the initial quantity limit will reject with a PA-required message.

Key Definitions

Eucrisa (crisaborole)

DrugEucrisa (crisaborole) topical ointment

IndicationTopical treatment of mild to moderate atopic dermatitis

Minimum agePatients 3 months of age and older

Medium or higher potency topical corticosteroid

DefinitionMedium or higher potency topical corticosteroids — examples listed in Table 1 of the policy document

Examples (medium potency)betamethasone valerate 0.1% cream/lotion/foam; clocortolone pivalate 0.1% cream; desonide 0.05% lotion/ointment

Examples (higher potency)

Clinical Background

Eucrisa (crisaborole) is a topical nonsteroidal phosphodiesterase-4 (PDE4) inhibitor that is FDA-approved for the treatment of mild to moderate atopic dermatitis in patients who meet the age indication of 3 months or older.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEucrisa (crisaborole) step therapy and quantity limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when prescribing Eucrisa and document clinical response or >5% BSA when requesting additional quantities.

SourceLink

On This Page

120 grams per 25 days

Increased 3-month limit when >5% BSA360 grams per 75 days

Initial step therapy applies to Eucrisa (crisaborole) — includes specified Rx and OTC products
If patient meets initial step therapy, quantity limits below apply; if requesting more than the initial limit, PA required

Documentation Required

Clinical Response and BSA Documentation Required

Clinical documentation is required for continuation/renewal requests. For continuation of therapy, documentation must show clinical response and, when applicable, body surface area (BSA) involvement. Clinical response may include improvement or resolution of signs/symptoms such as erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus.

For continuation requests, document achieved or maintained positive clinical response (examples listed above)
Document BSA when greater than 5% where applicable

Denial Risk

If the Patient Requests More Than the Initial Quantity Limit

If the patient is requesting more than the initial quantity limit, the claim will reject with a message indicating that a prior authorization is required. Quantity limits for Eucrisa (crisaborole) are applied per fill period to allow time for refill processing.

Initial month limit: 60 grams (25 days) — 180 grams (75 days) for 3-month supply
Quantity limit example for greater than 5% BSA: 120 grams per 25 days or 360 grams per 75 days

betamethasone dipropionate 0.05% cream/ointment; desoximetasone 0.05% cream; fluticasone propionate formulations