CurrentAvMedPolicy N/A

Anzupgo (delgocitinib) prior authorization and step-edit

Governs pharmacy prior authorization and step-therapy requirements for Anzupgo (delgocitinib) for AvMed members; applies to prescribers and specialty pharmacy processing requests.

Policy Summary

PayerAvMed

PolicyAnzupgo (delgocitinib) prior authorization and step-edit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation demonstrating trials of required topical and systemic therapies and chart notes showing clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 tubequantity limit

6 moinitial auth

12 moreauthorization

>=18age

Coverage Criteria for Anzupgo (delgocitinib)

Initial Authorization

Covered when ALL of the following are met

Initial Authorization Criteria: Member is 18 years of age or older; prescribed by or in consultation with a Dermatologist; diagnosis of moderate to severe chronic hand eczema for >= 3 months; member has tried and failed 30 days of therapy with TWO high-potency topical corticosteroids within the past 180 days (chart notes documenting contraindication(s) or intolerance must be attached; trials will be verified using pharmacy claims and/or submitted chart notes); member has tried and failed TWO of the following therapies within the past 180 days (chart notes documenting contraindication(s) or intolerance must be attached; trials will be verified using pharmacy claims and/or submitted chart notes): 30 days tacrolimus (Protopic) ointment; oral prednisone 0.5 mg/kg daily; oral immunosuppressants (e.g., azathioprine, cyclosporine, methotrexate); 90 days phototherapy (UVB or PUVA); medication will NOT be used in combination with other biologic disease-modifying antirheumatic drugs (e.g., Humira, Enbrel, Taltz, Stelara), JAK inhibitors (e.g., Xeljanz, Rinvoq, Opzelura), or potent immunosuppressants (e.g., azathioprine, cyclosporine).

All documentation including chart notes and pharmacy claims must be provided.

Continuation / Reauthorization

Reauthorization criteria

Policy Summary

PayerAvMed

PolicyAnzupgo (delgocitinib) prior authorization and step-edit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation demonstrating trials of required topical and systemic therapies and chart notes showing clinical response for reauthorization.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage for Anzupgo (delgocitinib) requires prior authorization. Initial approval is for 6 months with reauthorization intervals of 12 months. All approval criteria must be met and documented; supporting chart notes, laboratory results, diagnostics, and pharmacy claims shall be submitted with the request. The medication is dispensed through the plan-designated specialty pharmacy (Proprium Rx) and is subject to a quantity limit of 1 tube (60 grams) per 28 days.

The policy prohibits initiation of therapy using manufacturer samples to meet step or prior authorization requirements. If the requested medication is non-formulary for the member’s plan, documentation of medical necessity must be provided. Prior therapies listed in the clinical criteria will be verified via pharmacy paid claims or submitted chart notes and incomplete or illegible requests may be denied.

Initial Therapy

Initial authorization criteria

Initial: See Initial Authorization criteria: age >=18; dermatologist prescriber or consultation; diagnosis of moderate to severe chronic hand eczema >= 3 months; prior failure of 30 days of TWO high-potency topical corticosteroids within past 180 days; prior failure of TWO therapies from: tacrolimus ointment 30 days, oral prednisone 0.5 mg/kg daily, oral immunosuppressants (e.g., azathioprine, cyclosporine, methotrexate), or 90 days phototherapy (UVB or PUVA) within past 180 days; medication will not be used in combination with other biologic DMARDs, JAK inhibitors, or potent immunosuppressants.

Trials will be verified by pharmacy claims or submitted chart notes; attach chart notes documenting contraindication(s) or intolerance if applicable.

Step Therapy Requirements

Requirement	Documentation / Verification
Member is 18 years of age or older
Prescribed by or in consultation with a Dermatologist
Diagnosis of moderate to severe chronic hand eczema for >= 3 months
Tried and failed 30 days of therapy with TWO high-potency topical corticosteroids within the past 180 days (or documented contraindication/intolerance)
Tried and failed TWO of the following within the past 180 days: 30 days tacrolimus ointment; oral prednisone 0.5 mg/kg daily; oral immunosuppressants (e.g., azathioprine, cyclosporine, methotrexate); or 90 days phototherapy (UVB or PUVA)
Medication will NOT be used in combination with other biologic DMARDs, JAK inhibitors, or potent immunosuppressants
All trials must be documented; prior therapies will be verified via pharmacy claims and/or submitted chart notes. Chart notes documenting contraindication(s) or intolerance must be attached. For reauthorization, chart notes must document positive clinical response to therapy.

Provider Actions and Required Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Initial approval up to 6 months; reauthorization up to 12 months. Requests may be delayed or denied if the request is incomplete, incorrect, or illegible.

Initial authorization length: 6 months
Reauthorization length: 12 months

Step Therapy

Step Therapy Requirement

Step therapy required. Member must have failed specified topical and systemic therapies prior to approval; trials must be documented in chart notes and may be verified via pharmacy claims.

Failure of 30 days of TWO high‑potency topical corticosteroids within past 180 days
Failure of TWO systemic/other therapies within past 180 days (select from tacrolimus ointment 30 days; oral prednisone 0.5 mg/kg daily; oral immunosuppressants such as azathioprine, cyclosporine, methotrexate; 90 days phototherapy)
Trials must be documented (chart notes) or verified via pharmacy claims

Documentation Required

Required Documentation

Required documentation: prescriber signature (hand-signed; preprinted stamps not valid), member and prescriber information (including AvMed ID, DOB, NPI), office contact phone/fax, and complete drug/diagnosis details. Chart notes, lab results, and diagnostics supporting each checked clinical criterion must be provided or the request may be denied.

Prescriber hand‑signature required (stamps not valid)
Include Member AvMed ID and DOB, Prescriber name and NPI, office contact name, phone and fax
Provide drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight if applicable
Attach chart notes, lab results, diagnostics to support clinical criteria

Denial Risk

Triggers for Denial

Denial triggers: incomplete, incorrect, or illegible requests; missing supporting documentation (chart notes, labs, diagnostics); lack of required prior therapy trials; use in combination with prohibited biologics/JAK inhibitors or potent immunosuppressants; use of samples to satisfy step-edit/authorization.

Incomplete/incorrect/illegible requests may be delayed or denied
Missing chart notes, lab results, or diagnostics will lead to denial
Failure to document required prior therapy trials will result in denial
Requests for combination therapy with other biologics, JAK inhibitors, or potent immunosuppressants will be denied
Use of drug samples does not satisfy step therapy requirements

OpenPayer

Anzupgo (delgocitinib) prior authorization and step-edit

Coverage Criteria for Anzupgo (delgocitinib)

Initial Therapy

Continuation / Reauthorization

Step Therapy Requirements

Coding and Diagnosis Requirements

Quantity Limits and Dosing

Provider Actions and Required Documentation

Site of Care / Dispensing

Background

Definitions