CurrentAvMedPolicy N/A

Cibinqo

Prior authorization form and clinical criteria for coverage of Cibinqo (abrocitinib) for treatment of moderate-to-severe atopic dermatitis in AvMed members aged 12 and older, including required trials of topical, phototherapy, and systemic therapies and prescribing/combination restrictions. Includes quantity limit and dosing guidance.

Policy Summary

PayerAvMed

PolicyCibinqo

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and print name on the prior authorization request and fax the completed form with supporting documentation to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes for this policy.

1Quantity limit (tablets/day)

>=12Minimum age (years)

4Required therapy categories tried/failed

4Severity measures acceptable

Coverage Summary

Cibinqo (abrocitinib) is covered with criteria for treatment of moderate-to-severe atopic dermatitis in AvMed members aged >= 12 years. The prior authorization is a form-based process requiring documentation of disease severity and prior therapy trials. Dosing guidance: initiate at 100 mg once daily with the option to increase to 200 mg once daily for patients not responding to 100 mg. Medication is dispensed via Specialty Pharmacy and a quantity limit of 1 tablet per day applies.

Initial Authorization / Clinical Criteria

All criteria must be met for approval. To support each checked line, documentation (lab results, diagnostics, chart notes) must be provided.

ALL of the following

ALL of the following
- Diagnosis: Moderate-to-Severe Atopic Dermatitis
ONE of
- Body Surface Area (BSA) involvement >10%>10%
- Eczema Area and Severity Index (EASI) score ≥ 16≥ 16
- Investigator's Global Assessment (IGA) score ≥ 3≥ 3
- Scoring Atopic Dermatitis (SCORAD) score ≥ 25≥ 25
ALL of the following
- Prescribed by or in consultation with an Allergist, Dermatologist or Immunologist
ALL of the following
- Member is 12 years of age or older>= 12 years
ALL of the following
- Member is NOT receiving Cibinqo in combination with other JAK inhibitors, biologic immunomodulators, or with other immunosuppressants
Member has tried and failed, has a contraindication, or intolerance to ALL four of the following therapy categories (documentation required; trials verified via pharmacy claims or chart notes)
- 30 days (14 days for very high potency) of therapy with ONE medium to very-high potency topical corticosteroid in the past 180 days30 days (14 days for very high potency) within past 180 days
  14 days acceptable for very high potency; timeframe: within past 180 days
- ONE of
  - tacrolimus 0.03% or 0.1% ointment
  - pimecrolimus 1% cream
    requires prior authorization
- 90 days of phototherapy (e.g., NB UV-B, PUVA) unless the member is not a candidate and/or has an intolerance or contraindication to therapy90 days

Provider Actions & Prior Authorization

Prior Authorization

Submit prior authorization request

Prescribing physician must sign and clearly print name on the prior authorization request (preprinted stamps not valid). Fax the completed form and supporting documentation (chart notes, lab results) to 1-305-671-0200. Incomplete, incorrect, or illegible information may delay or deny authorization.

Documentation Required

Provide documentation of disease severity and prior therapy trials

Attach chart notes documenting disease severity using BSA, EASI, IGA, or SCORAD as applicable. Also include documentation of trials, contraindications, or intolerances to the required topical therapies, phototherapy, and systemic immunosuppressants. Prior therapies will be verified using pharmacy paid claims and/or submitted chart notes.

Billing Rule

Quantity limit

Quantity limit: 1 tablet per day.

Documentation Required

Specialty pharmacy dispensing

Medication is dispensed by Specialty Pharmacy - Proprium Rx. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Background & Definitions

This is a form-based prior authorization intended for Cibinqo (abrocitinib) with required documentation and prescriber signature on the request. Approval requires prior trials of topical therapies, phototherapy, and systemic immunosuppressants unless contraindicated, consistent with the scope for members aged 12 and older.

Term	Definition
Cibinqo	Brand name for abrocitinib, a JAK inhibitor for atopic dermatitis (as referenced on form).

Policy Summary

PayerAvMed

PolicyCibinqo

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and print name on the prior authorization request and fax the completed form with supporting documentation to 1-305-671-0200.

SourceLink

On This Page

OpenPayer

Cibinqo

Coverage Summary

Initial Authorization / Clinical Criteria

Continuation Therapy Criteria

Unproven / Exclusions

Applicable Codes

Provider Actions & Prior Authorization

Background & Definitions

Clinical Evidence

Revision History