CurrentAvMedPolicy N/A

Olumiant (baricitinib) prior authorization

Prior authorization/step-edit form and clinical criteria for coverage of Olumiant (baricitinib) for rheumatoid arthritis and alopecia areata, including required prescriber specialty, prior therapy failures, dosing, and documentation requirements. Also states combination therapy exclusions and specialty pharmacy handling.

Policy Summary

PayerAvMed

PolicyOlumiant (baricitinib) prior authorization

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

Key ActionComplete the prior authorization form with prescriber signature and submit chart notes, lab results, SALT score (for alopecia), and pharmacy paid claims to verify prior therapies; fax to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

Approved by Pharmacy and Therapeutics Committee: 10/18/2018; 2/16/2023; 8/17/2023; 1/18/2024; 11/21/2024

2Covered Indications

>=3 monthsRequired prior therapy duration

90/130 daysContinuation supply verification

Coverage Summary

Prior authorization/step-edit form and clinical criteria for Olumiant (baricitinib) covering moderate-to-severe active rheumatoid arthritis and alopecia areata. For rheumatoid arthritis the request requires the patient has the diagnosis, is prescribed by a Rheumatologist, has tried and failed at least ONE conventional DMARD for at least 3 months (hydroxychloroquine, leflunomide, methotrexate, or sulfasalazine), and either has failed or is intolerant/contraindicated to TWO preferred biologics or meets continuation criteria of being established on Olumiant for at least 90 days with a prescription claims history showing at least a 90-day supply dispensed within the past 130 days. The recommended dose for rheumatoid arthritis is 2 mg by mouth once daily.

For alopecia areata the criteria require the member be ≥18 years old, prescribed by or in consultation with a Dermatologist, have a diagnosis of alopecia areata with > 50% scalp hair loss (SALT) for more than 6 months (chart notes with SALT score must be submitted), not have hair loss from other causes, and have experienced failure, intolerance, or contraindication to ONE of the listed therapies used for at least 3 months (oral corticosteroids, oral immunosuppressants, intralesional corticosteroids, or topical immunotherapy). Recommended starting dose is 2 mg once daily with escalation to 4 mg once daily if inadequate response and reduction back to 2 mg once daily once adequate response is achieved.

The form requires prescriber signature and supporting documentation (chart notes, lab results, SALT score, pharmacy paid claims) to verify diagnoses, prior therapy failures, and dispensed supplies. Combination use of Olumiant with other JAK inhibitors, biologic immunomodulators, or other potent immunosuppressants is explicitly not permitted. The medication is dispensed via the specified specialty pharmacy, Proprium Rx.

Moderate-to-Severe Active Rheumatoid Arthritis - Approval Criteria

All criteria must be met for approval. To support each line checked, documentation must be provided.

ALL of the following

Member has a diagnosis of moderate- to-severe active rheumatoid arthritis
Prescribed by a Rheumatologist
Member has tried and failed at least ONE of the following DMARD therapies for at least three (3) months>= 3 months
ONE of
- hydroxychloroquine
- leflunomide
- methotrexate
- sulfasalazine
Member meets ONE of the following
- Member tried and failed, has a contraindication, or intolerance to TWO of the PREFERRED biologics (verified by chart notes or pharmacy paid claims)Two preferred biologics
- TWO of the following preferred biologics
  - Preferred adalimumab product
  - Enbrel
  - Rinvoq / Rinvoq LQ
  - Preferred tocilizumab product: Actemra SC or Tyenne SC
Recommended Dose: 2 mg by mouth once daily

Alopecia Areata - Approval Criteria

All criteria must be met for approval. Documentation (including SALT score) must be submitted.

ALL of the following

Member is 18 years of age or older>= 18 years
Prescribed by or in consultation with a Dermatologist
Member has a diagnosis of alopecia areata
Member has > 50% of scalp hair loss measured by the Severity of Alopecia Tool (SALT) for more than 6 months (chart notes with documentation of SALT score must be submitted)> 50% scalp hair loss for more than 6 months
SALT score required in documentation
Member does NOT have hair loss due to other forms of alopecia (i.e., androgenetic alopecia, chemotherapy induced, trichotillomania, telogen effluviums, and systemic lupus erythematosus)
Member has experienced treatment failure, has a contraindication or intolerance to ONE of the following therapies used for at least three (3) months (chart notes documenting treatment failure must be submitted)>= 3 months
ONE of
- Oral corticosteroids (e.g., prednisone)
- Oral immunosuppressants (e.g., azathioprine, cyclosporine, methotrexate)
- Intralesional corticosteroids (e.g., triamcinolone acetonide 5-10 mg/mL)
- Topical immunotherapy treatment (e.g., SADBE; DPCP)
Recommended Dose: 2 mg by mouth once daily; if response is inadequate may increase to 4 mg once daily. In patients receiving 4 mg once daily, reduce dose to 2 mg once daily once an adequate response is achieved.2 mg daily; may increase to 4 mg; reduce to 2 mg after response
Member is NOT receiving Olumiant in combination with other JAK inhibitors, biologic immunomodulators, or with other potent immunosuppressants
Combination therapy exclusion - not permitted

Provider Actions / Prior Authorization Requirements

Prior Authorization

Complete prior authorization form and prescriber signature required

Complete the prior authorization request form with the prescribing physician’s handwritten signature and printed name (preprinted stamps not valid). Fax the completed form to 1-305-671-0200. Incomplete, illegible, or unsigned forms may delay authorization.

Documentation Required

Submit documentation of prior therapy and clinical measures

Provide supporting clinical documentation including chart notes, relevant lab results, Severity of Alopecia Tool (SALT) score for alopecia cases, and pharmacy paid claims to verify prior therapy failures, contraindications, or dispensed supplies as specified in the criteria. All documentation must be submitted or the request may be denied.

Documentation Required

Verification of prior therapies

Previous therapies will be verified through pharmacy paid claims or submitted chart notes. Use of samples to initiate therapy does not meet the step edit/preauthorization criteria and does not satisfy prior therapy requirements.

Denial Risk

Combination therapy exclusion

Use of concomitant therapy with more than one biologic immunomodulator, or combination of Olumiant with other JAK inhibitors or other potent immunosuppressants, is considered experimental/investigational, is not permitted, and may result in denial of the request.

Billing Rule

Specialty pharmacy dispensing

Medication is dispensed via Specialty Pharmacy (Proprium Rx). Not all drugs are covered under every plan; if a drug is non-formulary for the member’s plan, documentation of medical necessity may be required.

Background & Dispensing

This is a form-based prior authorization that requires the prescribing physician to sign and clearly print their name on the request; incomplete, illegible, or unsigned forms may delay authorization and should be faxed to the number on the form.

The form mandates submission of clinical documentation to support each checked criterion (e.g., chart notes, lab results, SALT score, and pharmacy paid claims) and notes that previous therapies will be verified through paid claims or submitted chart notes.

The policy states that concomitant therapy with more than one biologic immunomodulator, combination with other JAK inhibitors, or with other potent immunosuppressants is considered experimental/investigational and will NOT be permitted. Medication is provided by the Specialty Pharmacy Proprium Rx; non-formulary status may require medical necessity documentation.

Revision History

10/18/2018committee_approval

Approved by Pharmacy and Therapeutics Committee

2/16/2023committee_approval

Approved by Pharmacy and Therapeutics Committee

8/17/2023committee_approval

Approved by Pharmacy and Therapeutics Committee

1/18/2024committee_approval

Approved by Pharmacy and Therapeutics Committee

11/21/2024committee_approvalLatest

Approved by Pharmacy and Therapeutics Committee (most recent listed approval date)

Policy Summary

PayerAvMed

PolicyOlumiant (baricitinib) prior authorization

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Olumiant (baricitinib) prior authorization

Coverage Summary

Moderate-to-Severe Active Rheumatoid Arthritis - Approval Criteria

Alopecia Areata - Approval Criteria

Provider Actions / Prior Authorization Requirements

Key Thresholds & Definitions

Applicable Codes

Background & Dispensing

Revision History