CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Leqselvi (deuruxolitinib) for severe alopecia areata

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Pharmacy prior authorization coverage for Leqselvi in adult Georgia Medicaid members with severe alopecia areata.

Policy Summary

PayerCareSource Georgia

PolicyLeqselvi (deuruxolitinib) for severe alopecia areata

Policy CodePolicy GA-MED-P-366579

Change TypeAdded Olumiant failure requirement

Effective DateMay 1, 2026

Next Review DateNot specified

Key ActionDocument trial and failure of Olumiant before requesting initial Leqselvi authorization.

SourceLink

POLICY UPDATE CHANGES

The policy added a requirement for documented trial and failure of Olumiant before initial Leqselvi authorization.

8 mg twice dailyDose

60/30 daysQuantity limit

6 monthsInitial approval

12 monthsReauthorization

SALT ≤20Response threshold

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CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Leqselvi (deuruxolitinib) for severe alopecia areata

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

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Pharmacy prior authorization coverage for Leqselvi in adult Georgia Medicaid members with severe alopecia areata.

Policy Summary

PayerCareSource Georgia

PolicyLeqselvi (deuruxolitinib) for severe alopecia areata

Policy CodePolicy GA-MED-P-366579

Change TypeAdded Olumiant failure requirement

Effective DateMay 1, 2026

Next Review DateNot specified

Key ActionDocument trial and failure of Olumiant before requesting initial Leqselvi authorization.

SourceLink

POLICY UPDATE CHANGES

The policy added a requirement for documented trial and failure of Olumiant before initial Leqselvi authorization.

8 mg twice dailyDose

60/30 daysQuantity limit

6 monthsInitial approval

12 monthsReauthorization

SALT ≤20Response threshold

SALT ≥50Initial severity

Coverage Criteria

Initial Therapy Criteria

Covered for initial authorization when ALL of the following requirements are met.

Initial authorization

Severe alopecia areata diagnosis: The current episode has lasted at least 6 months with no spontaneous regrowth at any point, AND hair loss encompasses at least 50% of the scalp confirmed by a SALT score of 50 or higher.Episode ≥ 6 months; SALT ≥ 50
Both diagnostic severity elements are required.
Prior therapy failure: Documented trial and failure of topical immunotherapy, such as DPCP or SADBE, for 6 months, OR documented trial and failure of an oral corticosteroid for 6 weeks.Topical immunotherapy 6 months OR oral corticosteroid 6 weeks
At least one of the two therapies must have failed.
Required clinical and safety criteria: Member has had a trial and failure of Olumiant; absolute lymphocyte count is at least 500 cells/mm3; absolute neutrophil count is at least 1,000 cells/mm3; hemoglobin is at least 8 g/dl; chart notes document that the member is not a CYP2C9 poor metabolizer; tuberculosis testing has been completed or will be completed within the past 12 months; and the provider attests that the member does not have active hepatitis B or C, concomitant moderate or strong CYP2C9 inhibitor use, or concomitant use of other JAK inhibitors, biologic immunomodulators, cyclosporine, or other potent immunosuppressants.ALC ≥ 500 cells/mm3; ANC ≥ 1,000 cells/mm3; hemoglobin ≥ 8 g/dl
All listed clinical and safety conditions are required.
Dosing and quantity: Leqselvi is administered at 8 mg orally twice daily, with a quantity limit of 60 tablets per 30 days.8 mg twice daily; 60 tablets per 30 days

Reauthorization Criteria

Covered for reauthorization when the treatment-response requirement is met.

Continuation therapy: Chart notes document achievement of a SALT score of 20 or less.SALT ≤ 20

Approval is for an additional 12 months when this requirement is met.

Conditions or indications not listed in this policy are excluded from medical necessity consideration under this policy. Requests for other indications must be referred for evaluation under the Off-Label policy.

The provider must attest that the member does not have active hepatitis B or C and is not using moderate or strong CYP2C9 inhibitors. Concomitant use of other JAK inhibitors, biologic immunomodulators, cyclosporine, or other potent immunosuppressants is also excluded.

CareSource considers Leqselvi (deuruxolitinib) not medically necessary for the treatment of conditions or indications that are not listed in this policy. Other indications must be evaluated under the Off-Label policy.

Initial Authorization Criteria

Leqselvi Initial Authorization Criteria

Initial authorization for Leqselvi requires ALL of the following policy criteria.

Leqselvi initial authorization

Disease severity: The current episode is at least 6 months in duration with no spontaneous regrowth at any point, and hair loss encompasses at least 50% of the scalp confirmed by a SALT score of at least 50.Episode ≥ 6 months; SALT ≥ 50
Both elements are required.
Prior therapy: Documented trial and failure of topical immunotherapy, such as DPCP or SADBE, for 6 months, OR documented trial and failure of an oral corticosteroid for 6 weeks.Topical immunotherapy 6 months OR oral corticosteroid 6 weeks
One option is required.

Reauthorization Criteria

Leqselvi Reauthorization Criteria

Reauthorization requires documented clinical response.

Leqselvi continuation therapy: Chart notes must document achievement of a SALT score of 20 or less.SALT ≤ 20

Approval is for an additional 12 months when this requirement is met.

Clinical Thresholds and Required Values

Current Alopecia Areata Episode

Minimum episode duration6 months or longer

Spontaneous regrowthNo spontaneous regrowth at any point

Initial authorization requirementBoth the duration and no-regrowth requirements must be met

Initial Scalp Hair-Loss Severity

Minimum scalp hair loss50% or more of the scalp

SALT thresholdSALT score of 50 or higher

Confirmation requirementScalp hair loss must be confirmed by a SALT score of 50 or higher

Required Prior Therapy

Step	Required prior therapy	Duration	Requirement
1	Topical immunotherapy, such as DPCP or SADBE, OR an oral corticosteroid	Topical immunotherapy: 6 months; oral corticosteroid: 6 weeks	Documented trial and failure of one option

Quantity and Dispensing Limits

Quantity Limit

MedicationLeqselvi (deuruxolitinib)

Quantity limit60 tablets per 30 days

Administration8 mg orally twice daily

Authorization and Documentation Requirements

Prior Authorization

Initial Pharmacy Prior Authorization

Prior authorization is required for Leqselvi (deuruxolitinib). Initial authorization is available for adults with severe alopecia areata when all clinical, safety, prescriber, and dosing requirements are met.

Prescribed by or in consultation with a dermatologist.
Member is at least 18 years old.
Severe alopecia areata: current episode has lasted at least 6 months with no spontaneous regrowth, and scalp hair loss is at least 50% with a SALT score of 50 or higher.
Absolute lymphocyte count ≥ 500 cells/mm³, absolute neutrophil count ≥ 1,000 cells/mm³, and hemoglobin ≥ 8 g/dL.
Member is not a CYP2C9 poor metabolizer and has completed or will complete tuberculosis testing within the previous 12 months.
Provider attests there is no active hepatitis B or C, concomitant moderate or strong CYP2C9 inhibitor, or concomitant JAK inhibitor, biologic immunomodulator, cyclosporine, or other potent immunosuppressant.
Dose and quantity limit: 8 mg orally twice daily; 60 tablets per 30 days. Initial approval is for 6 months when all requirements are met.

Clinical Background

Leqselvi (deuruxolitinib) is an oral Janus kinase inhibitor indicated for adults with severe alopecia areata. Alopecia areata is a T-cell-mediated autoimmune, nonscarring form of hair loss that may affect quality of life, including through anxiety and depression. The policy uses the Severity of Alopecia Tool (SALT) to quantify scalp hair loss and assess treatment response; initial authorization requires substantial hair loss with a SALT score of at least 50.

Key Definitions

Alopecia Areata

ConditionAlopecia areata

Disease typeT-cell-mediated autoimmune, nonscarring form of hair loss

PathogenesisUnderlying immunoinflammatory pathogenesis

SALT Score

DefinitionSeverity of Alopecia Tool used to quantify scalp hair loss

Initial authorization thresholdSALT score of 50 or higher

Reauthorization thresholdSALT score of 20 or less

Policy Summary

PayerCareSource Georgia

PolicyLeqselvi (deuruxolitinib) for severe alopecia areata

Policy CodePolicy GA-MED-P-366579

Change TypeAdded Olumiant failure requirement

Effective DateMay 1, 2026

Next Review DateNot specified

Key ActionDocument trial and failure of Olumiant before requesting initial Leqselvi authorization.

SourceLink

On This Page

Additional required therapy and safety criteria: Member has had a trial and failure of Olumiant; absolute lymphocyte count is at least 500 cells/mm3; absolute neutrophil count is at least 1,000 cells/mm3; hemoglobin is at least 8 g/dl; the member is not a CYP2C9 poor metabolizer; tuberculosis testing has been completed or is scheduled within the past 12 months; and the provider attests that the member does not have active hepatitis B or C, use moderate or strong CYP2C9 inhibitors, or use other JAK inhibitors, biologic immunomodulators, cyclosporine, or other potent immunosuppressants.ALC ≥ 500 cells/mm3; ANC ≥ 1,000 cells/mm3; hemoglobin ≥ 8 g/dl

All safety requirements are required.

Dosing and quantity: Leqselvi is administered at 8 mg orally twice daily, with a quantity limit of 60 tablets per 30 days.8 mg twice daily; 60 tablets per 30 days

Topical Immunotherapy Trial

Required therapyTopical immunotherapy, such as DPCP or SADBE

Trial duration6 months

Treatment outcomeDocumented trial and failure is required

Oral Corticosteroid Trial

Required therapyOral corticosteroid

Trial duration6 weeks

Treatment outcomeDocumented trial and failure is required

Absolute Lymphocyte Count

Laboratory measureAbsolute lymphocyte count

Minimum threshold≥ 500 cells/mm3

DocumentationThe value must be documented in chart notes

Absolute Neutrophil Count

Laboratory measureAbsolute neutrophil count

Minimum threshold≥ 1,000 cells/mm3

DocumentationThe value must be documented in chart notes

Hemoglobin

Laboratory measureHemoglobin

Minimum threshold≥ 8 g/dl

DocumentationThe value must be documented in chart notes

Tuberculosis Testing

Required testTuberculosis test

Completion windowCompleted within the past 12 months

Alternative timingThe test may be scheduled for completion within the past 12 months

Reauthorization Treatment Response

Treatment stageReauthorization

Required SALT responseSALT score of 20 or less

DocumentationChart notes must document achievement of the required score

Prior Authorization

Reauthorization Required

For reauthorization, the chart must demonstrate the required treatment response. When the reauthorization criterion is met, approval may be extended for an additional 12 months.

Chart notes must document achievement of a SALT score of 20 or less.
Additional authorization duration: 12 months.

Step Therapy

Required Prior Therapies

The member must have documented trial and failure of the required prior therapies before initial authorization.

Trial and failure of topical immunotherapy, such as DPCP or SADBE, for 6 months; or
Trial and failure of an oral corticosteroid for 6 weeks; and
Trial and failure of Olumiant.

Documentation Required

Initial Authorization Documentation

Submit clinical chart documentation supporting every initial-authorization criterion, including diagnosis severity, prior treatment failures, laboratory values, metabolic status, tuberculosis testing, contraindication screening, and the prescribed regimen.

Age of at least 18 years and prescription by or consultation with a dermatologist.
Severe alopecia areata with an episode lasting at least 6 months, no spontaneous regrowth, at least 50% scalp hair loss, and SALT score ≥ 50.
Documented trial and failure of one qualifying prior therapy and Olumiant.
Absolute lymphocyte count ≥ 500 cells/mm³, absolute neutrophil count ≥ 1,000 cells/mm³, and hemoglobin ≥ 8 g/dL.
Documentation that the member is not a CYP2C9 poor metabolizer and has had or will complete tuberculosis testing within the past 12 months.
Provider attestation that the member does not have active hepatitis B or C or prohibited concomitant therapies.
Prescription for 8 mg twice daily within the limit of 60 tablets per 30 days.

Documentation Required

Reauthorization Documentation

Reauthorization submissions must include chart notes documenting that the member achieved the required SALT response on therapy.

Required response: SALT score of 20 or less.
The documented response supports an additional 12 months of authorization.

Denial Risk

Initial Criteria Not Met

Initial authorization may be denied when any required criterion is not met or cannot be verified in the submitted documentation.

Member is under 18, or the medication is not prescribed by or in consultation with a dermatologist.
Diagnosis does not meet the severe alopecia areata duration, regrowth, scalp hair-loss, or SALT requirements.
Required trials and failures of a qualifying prior therapy and Olumiant are absent or undocumented.
Required laboratory values, CYP2C9 status, tuberculosis testing, or safety attestations are missing or outside the specified requirements.
Requested dose or quantity exceeds 8 mg twice daily or 60 tablets per 30 days.

Denial Risk

Required Treatment Response Not Documented

Reauthorization may be denied when the submitted chart notes do not document achievement of a SALT score of 20 or less.

Include a current chart-documented SALT score of ≤ 20 with the reauthorization request.
Without the required treatment response documentation, the additional 12-month authorization requirement is not met.

Denial Risk

Unlisted or Off-Label Indication

Leqselvi is not medically necessary for conditions or indications not listed in this policy. Requests for another indication must be evaluated under the applicable Off-Label policy.

Covered indication described in this policy: severe alopecia areata in adults meeting the stated criteria.
Unlisted or off-label indications are not covered under these criteria and require separate evaluation under the Off-Label policy.