Topical PDE-4 Inhibitors – Enhanced & Essential

Restricted Product(s)

• Eucrisa (crisaborole)
• Zoryve cream (roflumilast 0.15%) 
• Zoryve cream (roflumilast 0.3%) 
• Zoryve foam (roflumilast 0.3%)

FDA Approved Use

• Eucrisa
  • For the topical treatment of mild to moderate atopic dermatitis
• Zoryve 0.15% cream
  • For the topical treatment of mild to moderate atopic dermatitis
• Zoryve 0.3% cream 
  • For the topical treatment of plaque psoriasis 
• Zoryve foam 
  • For the topical treatment of seborrheic dermatitis

Criteria for Approval of Restricted Product(s)

1. The request is for Eucrisa; AND
   1. The patient has tried and failed ONE generic topical corticosteroid; OR
      1. The patient has a documented allergy, intolerance, or contraindication to ALL topical corticosteroids; OR
   2. The requested medication is for use on the face (including eyelids), neck, or skin folds (e.g. groin, armpit/under arm); OR 
2. The request is for Zoryve 0.15% cream; AND
   1. The patient has a diagnosis of atopic dermatitis; AND
   2. The patient has tried and failed ONE of the following: a generic topical corticosteroid or a topical calcineurin inhibitor; OR
      1. The patient has a documented allergy, intolerance, or contraindication to ALL of the alternatives that have not been tried; OR
3. The request is for Zoryve 0.3% cream; AND
   1. The patient has a diagnosis of plaque psoriasis; AND
   2. The patient has tried and failed ONE of the following: generic calcipotriene, generic topical corticosteroid, or generic tazarotene; OR
      1. The patient has a documented allergy, intolerance, or contraindication to ALL of the alternatives that have not been tried; OR 
4. The request is for Zoryve foam; AND
   1. The patient has a diagnosis of seborrheic dermatitis; AND
   2. The patient has tried and failed ONE of the following: generic ketoconazole cream/shampoo, generic ciclopirox gel/shampoo, or a generic topical corticosteroid; OR 
      1. The patient has a documented allergy, intolerance, or contraindication to ALL of the alternatives that have not been tried; AND
5. For formularies that exclude (non-formulary) the request medication, Non-formulary Exception Criteria applies
   
   Duration of Approval: 365 days (1 year)

References

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.

July 2024: Added new to market Zoryve 0.15% cream to policy.
Jan 2024: Original utilization management criteria issued.