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.