Pharmacy Prior Authorization Criteria

Atopic Dermatitis Topical Agents

Indications for Prior Authorization

Eucrisa (crisaborole) ointment

• For diagnosis of Atopic Dermatitis
  Indicated for topical treatment of mild to moderate atopic dermatitis in adult and pediatric patients 3 months of age and older.

Criteria

Eucrisa

Step Therapy

Length of Approval: 12 Month(s)
For diagnosis of Atopic Dermatitis

• Trial and failure (of a minimum 30 day supply), contraindication, or intolerance to one prescription strength topical corticosteroid (see Table 1 in Background section), unless the affected area is sensitive (i.e., face, axillae, groin). [2]
OR
• Trial and failure (of a minimum 30-day supply) or intolerance to one generic topical calcineurin inhibitor (e.g., tacrolimus ointment), unless the patient is not a candidate for therapy (e.g., immunocompromised) [3]

P & T Revisions

2024-01-31, 2023-01-29, 2022-01-23, 2021-06-01, 2021-01-19, 2020-03-31, 2020-02-12

References

1. Eucrisa Prescribing Information. Pfizer, Inc. New York, NY. April 2023.
2. Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023; Epub ahead of print.
3. Protopic Prescribing Information. Leo Pharma Inc. Madison, NJ. February 2019.

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Revision History

• 2024-01-31: Annual review - no criteria changes; background updates
• 2023-01-29: Annual review - no criteria changes
• 2022-01-23: Annual review - no criteria changes
• 2021-06-01: Program update to allow for trial of a topical calcineurin inhibitor.
• 2021-01-19: Annual Review: added minimum trial and failure duration verbiage
• 2020-03-31: Program Update
• 2020-02-12: Annual Review

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