Crisaborole (Eucrisa)

SELF ADMINISTRATION - TOPICAL

Indications for Prior Authorization:

  • Treatment of mild to moderate atopic dermatitis in patients 2 years of age and older

Patients must meet the following criteria for the indication(s) above:

  • Prescribed by or in collaboration with a dermatologist, AND
  • Chart note documentation required documenting diagnosis of mild-to-moderate atopic dermatitis, drugs tried and failed and reason for failure, AND
  • Patient is 2 years of age or older, AND
  • Exacerbating factor that could contribute to the member's atopic dermatitis have been evaluated and addressed (e.g., non-compliance with therapy, environmental triggers, allergy patch testing, etc.); AND
  • Patient has tried and failed a 2-week trial of two generic medium to high potency corticosteroids unless contraindicated (e.g., areas involving the face, neck or intertriginous areas), AND
  • Patient has tried and failed Elidel

Dosing:

  • Apply topially to affected areas twice daily

Approval:

  • 3 months

Last review date: March 20, 2019