CurrentNeighborhood Health Plan of Rhode IslandPolicy 3199-E

Eucrisa (crisaborole) topical therapy — coverage criteria and prior authorization

Coverage and prior authorization, step therapy, and quantity limits for Eucrisa (crisaborole) for treatment of mild to moderate atopic dermatitis for applicable Marketplace and Aetna individual/small group products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEucrisa (crisaborole) topical therapy — coverage criteria and prior authorization

Policy CodePolicy 3199-E

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when the initial step therapy criteria are not met or when requesting quantities above the standard limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsInitial duration

12 monthsContinuation duration

60 g1-month limit

180 g3-month limit

5% BSAHigher-quantity threshold

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Coverage Criteria

Initial authorization criteria

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.

Clinical qualifying conditions

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

Quantity and BSA for additional quantities: If additional quantities are being requested, then 5 percent or greater body surface area is affected.5% BSA

Continuation of therapy criteria

Continuation authorization may be granted 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 (e.g., improvement in or resolution of any of the following signs and symptoms: erythema, edema, xerosis, erosions, excoriations, oozing/crusting, lichenification, or pruritus).

Quantity/BSA for more quantity: If additional quantities are being requested, then 5 percent or greater body surface area is affected.5% BSA

Standard coverage for Eucrisa (crisaborole) under the prescription benefit requires that the topical corticosteroid step therapy be met before payment will be allowed. Specifically, if the patient has 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, the requested product may be paid subject to applicable quantity limits. If that step is not met, the claim will reject and a prior authorization (PA) is required; PA criteria will then be applied to requests submitted for evaluation.

When the initial step therapy requirement is satisfied, quantity limits apply. Requests that exceed the initial quantity limit will also reject and require PA review. Required clinical documentation for PA includes evidence of age (≥3 months), the treated indication (mild to moderate atopic dermatitis), any prior trial, intolerance, or contraindication to a medium or higher potency topical corticosteroid when claimed, and body surface area when requesting quantities above standard limits.

Use of the requested drug for indications other than mild to moderate atopic dermatitis is not supported by this policy; authorization language and coverage criteria are limited to mild to moderate atopic dermatitis in patients aged 3 months and older.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

If the patient has not filled a prescription for at least a one day supply of a medium or higher potency topical corticosteroid within the past 180 days under a prescription benefit administered by CVS Caremark, the claim will reject with a message indicating that a prior authorization (PA) is required. When step therapy or quantity limits are not met, submit a PA for evaluation to the PA unit. If the patient meets the initial step therapy criteria, quantity limits below will apply; requests exceeding those limits will reject and require PA.

Prior authorization required when no fill of a medium or higher potency topical corticosteroid in the past 180 days
PA required when requested quantity exceeds the initial quantity limit

Step Therapy

Topical Corticosteroid Step Requirement

A trial of a medium or higher potency topical corticosteroid is required prior to coverage of the requested agent unless the patient meets an allowed exception (intolerance, contraindication, or inadequate response). Examples of medium, high, and very high potency topical corticosteroids are provided below; these examples include but are not limited to the listed agents.

Examples of medium potency: betamethasone dipropionate lotion/spray 0.05%, betamethasone valerate cream/lotion 0.1%, clocortolone pivalate cream 0.1%, desonide 0.05%, fluocinolone acetonide 0.025%, fluticasone propionate 0.05%, hydrocortisone butyrate 0.1%, hydrocortisone probutate 0.1%, hydrocortisone valerate 0.2%, mometasone furoate 0.1%, prednicarbate 0.1%, triamcinolone acetonide 0.1%/0.025%/0.05%
Examples of high/very high potency: amcinonide 0.1%, betamethasone dipropionate 0.05% (cream/ointment/augmented), desoximetasone 0.25%/0.05%, diflorasone diacetate 0.05%, fluocinonide 0.05%, clobetasol propionate 0.05%, halobetasol propionate (and other very high potency agents)

Documentation Required

Required Clinical Documentation

Documentation must support the patient’s age, diagnosis, and the reason a medium or higher potency topical corticosteroid trial was not appropriate or was unsuccessful (e.g., intolerance, contraindication, or inadequate response). For requests exceeding quantity limits, documentation should include affected body surface area (BSA) and clinical response or rationale for additional quantity.

Confirm patient is ≥ 3 months of age (or document age if exception applies)
Indicate indication: mild to moderate atopic dermatitis
If no prior medium/high potency topical corticosteroid trial: document intolerance, contraindication, or inadequate response
For additional quantities: document % Body Surface Area affected (5% or greater triggers higher limits) and clinical response

Denial Risk

Claim Rejection Triggers and PA Submission

Claims will reject when step therapy or quantity limits are not met — messages will indicate that a prior authorization is required. Examples of reject triggers: no medium/high potency topical corticosteroid fill in past 180 days, requested quantity exceeds limits (see quantity limits). Submit PA with required documentation to avoid denial.

Reject trigger: No medium or higher potency topical corticosteroid fill in the past 180 days
Reject trigger: Requested quantity exceeds 60 g per 25 days (or 180 g per 75 days)
Reject trigger: For BSA ≥ 5% the applicable limits are 120 g per 25 days (or 360 g per 75 days); requests above these limits will reject
If claim rejects, submit PA with documentation to PA unit for review

Definitions

Eucrisa (crisaborole)

DrugEucrisa (crisaborole) topical ointment

Indication (FDA)Topical treatment of mild to moderate atopic dermatitis

Age indication (FDA label)Patients 3 months of age and older

Medium or higher potency topical corticosteroid (examples)

Representative medium-potency examplesBetamethasone dipropionate lotion/spray 0.05%; betamethasone valerate cream/lotion 0.1%; mometasone furoate cream/lotion/solution 0.1%; triamcinolone acetonide 0.1%

Representative high-potency examplesAmcinonide cream/ointment 0.1%; betamethasone dipropionate cream/ointment 0.05%; fluocinonide cream/ointment 0.05%

Representative very-high–potency examplesBetamethasone dipropionate augmented ointment/gel 0.05%; clobetasol propionate cream/ointment 0.05%; halobetasol propionate cream/ointment

Background

Eucrisa (crisaborole) is a topical nonsteroidal phosphodiesterase-4 (PDE4) inhibitor indicated for treatment of mild to moderate atopic dermatitis in patients aged 3 months and older. The policy applies a step-therapy approach that requires a prior filled prescription for a medium or higher potency topical corticosteroid within the past 180 days before standard prescription benefit coverage, with exceptions for young age (<2 years), use on sensitive skin areas (face, genitals, skin folds), inadequate response, intolerance, or contraindication to such corticosteroids. Quantity limits apply for standard fills and higher quantities require documentation of involvement of ≥5% body surface area and may trigger prior authorization.

OpenPayer

Eucrisa (crisaborole) topical therapy — coverage criteria and prior authorization

Coverage Criteria

Coding and Quantity Limits

Provider Actions and Prior Authorization

Definitions

Background