CurrentWashington State Health Care AuthorityPolicy 90.23.00.AA-3

Atopic Dermatitis Agents: Crisaborole (Eucrisa)

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This policy governs prior authorization and medical-necessity coverage for topical crisaborole (Eucrisa) for atopic dermatitis under Washington Apple Health, including initial approval, reauthorization, prior topical therapies, documentation, authorization duration, and quantity limits.

Policy Summary

PayerWashington State Health Care Authority

PolicyAtopic Dermatitis Agents: Crisaborole (Eucrisa)

Policy CodePolicy 90.23.00.AA-3

Change TypeRevised and clarified

Effective DateMay 1, 2020

Last ReviewAug 24, 2021

Next Review DateN/A

Key ActionDocument at least two preferred medium- or higher-potency topical corticosteroid trials and at least one topical calcineurin inhibitor trial before requesting crisaborole, unless an applicable exception is documented.

SourceLink

POLICY UPDATE CHANGES

The policy updated the minimum patient age to reflect the current crisaborole label.

The required topical corticosteroid trial duration was changed to a minimum of 28 days.

The quantity limits were updated to include the 100-gram tube size.

The policy clarified that baseline disease evaluation must include documentation of symptom severity.

The reauthorization criterion was clarified to require documentation of disease stability or improvement from baseline.

≥3 monthsMinimum patient age for initial coverage

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CurrentWashington State Health Care AuthorityPolicy 90.23.00.AA-3

Atopic Dermatitis Agents: Crisaborole (Eucrisa)

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Sign up for Washington State Health Care Authority Policy 90.23.00.AA-3 alerts

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Policy Summary

PayerWashington State Health Care Authority

PolicyAtopic Dermatitis Agents: Crisaborole (Eucrisa)

Policy CodePolicy 90.23.00.AA-3

Change TypeRevised and clarified

Effective DateMay 1, 2020

Last ReviewAug 24, 2021

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

The policy updated the minimum patient age to reflect the current crisaborole label.

The required topical corticosteroid trial duration was changed to a minimum of 28 days.

The quantity limits were updated to include the 100-gram tube size.

The policy clarified that baseline disease evaluation must include documentation of symptom severity.

The reauthorization criterion was clarified to require documentation of disease stability or improvement from baseline.

≥3 monthsMinimum patient age for initial coverage

Preferred topical corticosteroid trials required

28 daysMinimum trial duration

6 monthsInitial authorization duration

12 monthsReauthorization duration

1 tube/30 daysQuantity limit

Coverage Criteria

Initial Therapy

Crisaborole may be covered when ALL of the following initial-approval criteria are met.

Initial approval

Age: Patient is 3 months of age or older.≥3 months
Diagnosis and baseline assessment: Patient has atopic dermatitis with documentation of a baseline evaluation, including severity of symptoms.
Topical corticosteroid step therapy
- Exception to corticosteroid trial
  - Sensitive-area exception: Treatment involves sensitive areas such as the face, anogenital region, or skin folds that did not respond to low-potency desonide or hydrocortisone.
  - Steroid atrophy history: Patient has a history of steroid-induced atrophy.
  - Long-term use concern: Uninterrupted long-term topical corticosteroid use would be required.
  - Intolerance or contraindication: The corticosteroid treatment is contraindicated or not tolerated.
Topical calcineurin inhibitor step therapy
- Calcineurin inhibitor exception: A contraindication is documented, including age less than 2 years.

Continuation Therapy

Crisaborole may be reauthorized when ALL of the following criteria are met.

Reauthorization: Clinical documentation shows disease stability or improvement from baseline.Stable or improved from baseline

When met, reauthorization may be approved for 12 months.

Provider Requirements and Decision Risks

Prior Authorization

Prior Authorization for Non-Preferred New-to-Market Drugs

New-to-market drugs included in this class on the Apple Health Preferred Drug List are non-preferred and require prior authorization before coverage.

Non-preferred agents require an inadequate response or documented intolerance due to severe adverse reaction or contraindication to at least two preferred agents.
If only one preferred agent exists in the class, documentation of inadequate response to that one preferred agent is required.
The current Apple Health Preferred Drug List is available at https://www.hca.wa.gov/assets/billers-and-providers/applehealth-preferred-drug-list.xlsx.

Documentation Required

Initial Approval Criteria

Crisaborole may be approved initially when the patient is at least 3 months old, has documented atopic dermatitis with baseline severity assessment, and meets the required topical-treatment history.

Atopic Dermatitis Background

Atopic dermatitis is a chronic, noncontagious inflammatory disease of the skin, often referred to as eczema. It results from a combination of genetic and environmental factors and is characterized by extremely dry, itchy skin, commonly affecting the insides of the elbows, behind the knees, and the face, hands, and feet.

Key Definitions

Crisaborole

MedicationCrisaborole (Eucrisa) is a topical treatment for atopic dermatitis.

Drug classTopical phosphodiesterase 4 (PDE4) inhibitor.

MechanismAllows cyclic adenosine monophosphate (cAMP) to remain intact, helping decrease the proinflammatory response associated with atopic dermatitis.

Atopic dermatitis

DefinitionAtopic dermatitis is a chronic, non-contagious inflammatory disease of the skin.

Common nameOften referred to as eczema.

Characteristic features

Initial Crisaborole Approval

Initial crisaborole therapy may be covered when all clinical criteria are met.

Initial crisaborole therapy: Patient is at least 3 months old, has documented atopic dermatitis with baseline symptom severity, has completed the required preferred topical corticosteroid trials or has a qualifying exception, and has completed the required topical calcineurin inhibitor trial or has a documented contraindication.Age ≥3 months; corticosteroid trials ≥28 days; calcineurin inhibitor trial ≥28 days

If all criteria are met, initial approval may be granted for 6 months. Case-by-case approval may be considered for documented medically necessary or situational circumstances based on clinical reviewer judgment.

Crisaborole Reauthorization

Reauthorization requires clinical documentation of disease stability or improvement from baseline.

Continuation criterion: Disease is stable or improved from baseline based on clinical documentation.Stable or improved from baseline

Approval may be granted for 12 months when met.

Required Prior Therapies

Step	Required therapy	Duration and timing	Exceptions
1	Trial and failure of at least two preferred topical corticosteroids of medium or higher potency	Use daily for at least 28 days within the previous 6 months	The trial may be bypassed when contraindicated or not tolerated, including treatment of sensitive areas that did not respond to low-potency desonide or hydrocortisone, a history of steroid-induced atrophy, or the need for long-term uninterrupted use

Crisaborole Quantity Limits

Crisaborole (Eucrisa) quantity limit

60-gram tube1 (60 g) tube per 30 days.

100-gram tube1 (100 g) tube per 30 days.

Quantity-limit frequencyThe limit is one tube per 30 days, using either the 60-gram or 100-gram tube size.

Policy Summary

PayerWashington State Health Care Authority

PolicyAtopic Dermatitis Agents: Crisaborole (Eucrisa)

Policy CodePolicy 90.23.00.AA-3

Change TypeRevised and clarified

Effective DateMay 1, 2020

Last ReviewAug 24, 2021

Next Review DateN/A

SourceLink

On This Page

All required criteria must be met for approval up to 6 months.
A request that does not meet all criteria may be considered case-by-case when medically necessary or supported by situational circumstances, based on the clinical reviewer's professional judgment, for up to the initial authorization duration.

Documentation Required

Reauthorization Criteria

Crisaborole may be reauthorized when clinical documentation demonstrates disease stability or improvement from baseline.

When the reauthorization criterion is met, approval may be granted for 12 months.
A request that does not meet the criterion may be considered case-by-case when medically necessary or supported by situational circumstances, based on the clinical reviewer's professional judgment, for up to the reauthorization duration.

Step Therapy

Required Topical Therapy Trials

Document the required prior topical therapy trials before requesting initial crisaborole coverage.

Trial and failure of at least two preferred medium- or higher-potency topical corticosteroids, used daily for a minimum of 28 days within the previous 6 months, unless contraindicated or not tolerated.
Trial of at least one topical calcineurin inhibitor—such as pimecrolimus or tacrolimus—for a minimum of 28 days, unless contraindicated.

Documentation Required

Baseline Disease Assessment

Document the diagnosis of atopic dermatitis and the patient's baseline disease status before treatment.

The record must include a baseline evaluation of the disease, including symptom severity.
The patient must be 3 months of age or older.

Step Therapy

Topical Corticosteroid History

Document failure or inability to use the required preferred topical corticosteroids.

At least two preferred medium- or higher-potency corticosteroids must have been tried daily for at least 28 days within the previous 6 months and failed, unless contraindicated or not tolerated.
Relevant contraindications include treatment of sensitive areas—face, anogenital area, or skin folds—not responding to low-potency desonide or hydrocortisone; a history of steroid-induced atrophy; or the need for long-term uninterrupted use.

Step Therapy

Calcineurin Inhibitor History

Document a trial of a topical calcineurin inhibitor or the applicable contraindication.

At least one of pimecrolimus or tacrolimus must have been tried for a minimum of 28 days, unless contraindicated.
Age less than 2 years is identified as a contraindication to topical calcineurin inhibitor therapy.

Documentation Required

Reauthorization Response Documentation

For reauthorization, submit clinical documentation comparing the patient's current disease status with baseline.

The documentation must show that atopic dermatitis is stable or improved from baseline.

Denial Risk

Failure to Meet Clinical Criteria

A request may be denied when required clinical criteria are not established and no medically necessary or situational exception supports case-by-case approval.

Initial requests may be denied when the age requirement, diagnosis and baseline assessment, preferred corticosteroid trials, or calcineurin inhibitor trial or contraindication is not documented.
Reauthorization may be denied when disease stability or improvement from baseline is not documented.

Denial Risk

Insufficient Preferred-Agent History

Do not submit a non-preferred-agent request without adequate preferred-agent history or a documented exception.

Document inadequate response, severe adverse reaction, or contraindication to at least two preferred agents when two or more preferred agents are available.
When only one preferred agent is available, document inadequate response to that one preferred agent.
Requests lacking the required preferred-agent history may be denied.

Denial Risk

Quantity Limit Exceeded

Requests exceeding the established crisaborole quantity limit may be denied.

Allowed quantity is one 60 g tube per 30 days, or, where applicable, one 100 g tube per 30 days.
Do not request more than one tube per 30-day period without applicable authorization.

Characterized by extremely dry, itchy skin, typically affecting the insides of the elbows, behind the knees, and the face, hands, and feet.