Subject: Eucrisa PA with Limit 1565-C P04-2026

Drug

EUCRISA  (crisaborole)

Policy:

Indications

FDA-approved Indications

Eucrisa is indicated for topical treatment of mild to moderate atopic dermatitis in adult and pediatric patients 3 months of age and older.

Coverage Criteria

Atopic Dermatitis

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:

·        The patient is 3 months of age or older.

·        The patient meets ONE of the following criteria:

§  The patient is less than 2 years of age.

§  The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to a topical calcineurin inhibitor OR a medium or higher potency topical corticosteroid.

·        If additional quantities are being requested, then 5 percent or greater body surface area is affected.

Continuation of Therapy

Atopic Dermatitis

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:

·        The patient is 3 months of age or older.

·        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 (redness), edema (swelling), xerosis (dry skin), erosions, excoriations (evidence of scratching), oozing and crusting, lichenification (epidermal thickening), OR pruritus (itching)].

·        If additional quantities are being requested, then 5 percent or greater body surface area is affected.

Quantity Limits Apply

60 grams per 25 days or 180 grams per 75 days.

5 percent or greater Body Surface Area (BSA): 120 grams per 25 days or 360 grams per 75 days.

The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing.

Duration of Approval (DOA)

·        1565-C: Initial therapy DOA: 3 months; Continuation of therapy DOA: 12 months

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Eucrisa [package insert]. New York, NY: Pfizer Inc.; April 2023.

2.     Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2026. https://online.lexi.com. Accessed January 29, 2026.

3.     Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 01/29/2026).

4.     Eichenfield LF, Tom WL, et. al. Guidelines of care for the management of atopic dermatitis: Section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014; 71:116-32.

5.     Paller AS, Tom WL, et. al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016 Jul 1175(3)494-503.e6.

6.     U.S. Department of Health & Human Services. Burn Triage and Treatment – Thermal Injuries. Chemical Hazards Emergency Medical Management. January 20, 2026. Available at: https://chemm.hhs.gov/burns.htm. Accessed January 29, 2026.

7.     Eichenfield LF, Tom WL, et. al. Guidelines of Care for the Management of Atopic Dermatitis: Section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol 2014; 70:338-51.

8.     Sidbury RS, Alikhan A, Berovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023: 89(1): e1-e20.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

August 20, 2026