CurrentNeighborhood Health Plan of Rhode IslandPolicy 3199-E UDR 04-2024

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

This policy defines step therapy, prior authorization, and quantity limits for Eucrisa (crisaborole) prescribed for mild to moderate atopic dermatitis in patients aged 3 months and older under the payer's prescription benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy 3199-E UDR 04-2024

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when step therapy criteria are not met or when requested quantity exceeds initial limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsmin age

60 gmonth limit

180 g3-month limit

>5% BSABSA threshold

Authorization and Coverage Criteria

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Initial and continuation authorization criteria

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

Age requirement: Patient is 3 months of age or older

One of the following must be true

Sensitive area: Requested drug will be used on sensitive skin areas (face, genitals, or skin folds)
Young age: Patient is less than 2 years of age
Prior inadequate response: Patient experienced an inadequate treatment response to a medium or higher potency topical corticosteroid
Contraindication to corticosteroid: Patient has a contraindication that would prohibit a trial of a medium or higher potency topical corticosteroid
Intolerance to corticosteroid: Patient experienced an intolerance to a medium or higher potency topical corticosteroid

Clinical response for continuation: Patient has achieved or maintained a positive clinical response as evidenced by improvement or resolution of signs or symptoms such as erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus

Quantity/BSA: If additional quantities are requested, then 5 percent or greater body surface area must be affected>= 5% BSA

Drug and Quantity Coding

Referenced drug codingNDC | mixed

not specified

Policy references Eucrisa product and quantity limits; specific NDC/CPT/HCPCS codes are not provided in the document.

Body surface area threshold for increased quantity

Threshold>= 5% body surface area (BSA)

Standard initial limit60 g per 25 days (180 g per 75 days)

Increased quantity allowance>5% BSA → 120 g per 25 days (360 g per 75 days)

Documentation requirementBody surface area affected must be documented when requesting increased quantities (>5% BSA)

What Providers Must Do

Step Therapy

Step therapy and quantity limits

If the patient meets the initial step therapy criteria, the claim will process subject to the initial quantity limit. If the patient meets step therapy but requests more than the initial quantity limit, the claim will reject with a message indicating that a prior authorization (PA) is required. Authorization may be granted when all listed clinical criteria are met.

If initial step criteria are not met the claim will reject and a PA will be required.
If patient meets initial step therapy but requests quantities beyond the initial limit the claim will reject indicating PA required.
PA will be evaluated against the authorization criteria; authorization may be granted when ALL clinical criteria are met.

Documentation Required

Documentation requirements

Documentation submitted with PA requests should support the patient’s age (must be ≥ 3 months), the indication (mild to moderate atopic dermatitis), prior trials or contraindications/intolerance to medium or higher potency topical corticosteroids when applicable, and the extent of body surface area affected when additional quantities are requested.

Support age: patient is ≥ 3 months of age.
Indication: mild to moderate atopic dermatitis and location (sensitive skin areas such as face, genitals, or skin folds) when applicable.
Prior therapy: trial, intolerance, or contraindication to medium or higher potency topical corticosteroids, or documentation of inadequate response.
Quantity justification: if requesting > initial limit, document body surface area involved (≥5% BSA for greater quantity).

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests that do not meet the initial step therapy criteria or that exceed the initial quantity limits. When a PA is required it will be reviewed using the criteria in this policy and may be approved if all criteria are satisfied.

Claims that fail initial step therapy will reject with instructions to submit a PA.
Claims for quantities above the initial limit will reject with instructions to submit a PA for review.
Authorizations are evaluated against the clinical criteria; approvals are granted only when all required criteria are met.

Indication and Clinical Terms

Indication

IndicationTopical treatment of mild to moderate atopic dermatitis in adult and pediatric patients 3 months of age and older.

RouteTopical

Age requirementPatients aged ≥ 3 months

SeverityMild to moderate atopic dermatitis

Clinical response

DefinitionImprovement or resolution of signs/symptoms such as erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus.

PurposeUsed to determine eligibility for continuation of therapy

EvidenceClinical response must be documented to support continued authorization

Examples of signs/symptomsErythema (redness), edema (swelling), xerosis (dry skin), erosions, excoriations (scratching), oozing/crusting, lichenification (thickening), pruritus (itching)