CurrentCignaPolicy DQM019

Inflammatory Conditions - Olumiant Drug Quantity Management Policy - Per Days

Defines quantity limits and exceptions for Olumiant (baricitinib tablets) for Cigna-administered health benefit plans, including criteria for approving quantities beyond standard limits; applies to providers submitting claims for affected members.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Olumiant Drug Quantity Management Policy - Per Days

Policy CodePolicy DQM019

Change TypeNew policy

Effective DateFeb 15, 2026

Next Review DateN/A

Key ActionEnsure Drug Quantity Management rule is met at point of service; if not met, submit criteria-based request for approval (approvals provided for 1 year).

SourceLink

POLICY UPDATE CHANGES

New Policy created to provide overrides to existing quantity limits.

30max per 30 days (retail)

90max per 90 days (home delivery)

1 yearapproval duration

3tablet strengths

Coverage Criteria — Quantity Limits and Exceptions

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Drug Quantity Limits and Exceptions

Covered quantities and exceptions

Standard quantity limits: For Olumiant (baricitinib) 1 mg, 2 mg, and 4 mg tablets: retail maximum 30 tablets per 30 days; home delivery maximum 90 tablets per 90 days.30 per 30 days (retail); 90 per 90 days (home delivery)

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the criteria below. Approvals are provided for 1 year.

Exceptions to quantity limits: Approve the requested quantity for a 30-day supply at retail and a 90-day supply at home delivery when the patient has one of the following diagnoses: Aicardi-Goutières syndrome (AGS); chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature / proteasome-associated autoinflammatory syndrome (CANDLE/PRAAS); or stimulator of interferon genes associated vasculopathy with onset in infancy (SAVI).diagnosis match

Any other exception to the stated quantity limits is considered not medically necessary.

Exceptions to the stated Olumiant quantity limits are narrowly defined. Per policy, only requests that meet the specified diagnostic exceptions—Aicardi-Goutières syndrome (AGS), CANDLE/PRAAS, or SAVI—are considered medically necessary. Any other exception to the quantity limits is considered not medically necessary and will be denied.

Quantity limits for Olumiant are: retail — maximum 30 tablets per 30 days for each strength (1 mg, 2 mg, 4 mg) and home delivery — maximum 90 tablets per 90 days. Requests that do not match one of the three approved diagnostic exceptions should not be approved beyond these limits.

The only clinically supported justifications for exceeding the standard quantity limits are the three listed diagnoses. Specifically, if the patient does not have Aicardi-Goutières syndrome (AGS), CANDLE/PRAAS, or SAVI, the request for additional tablets does not meet policy criteria and is classified as not medically necessary.

When a request cites an alternative clinical rationale or a diagnosis other than AGS, CANDLE/PRAAS, or SAVI, do not override the quantity limits. Approvals beyond the limits are limited to cases where the member’s diagnosis explicitly matches one of the three exceptions identified in the policy.

Provider Actions, Billing & Prior Authorization

Prior Authorization

Point-of-service prior authorization required for Drug Quantity Management

The Drug Quantity Management rule for Olumiant must be met at the point of service; if the rule is not met, coverage will be determined by the criteria in this policy. Approvals issued under the program are provided for a duration of 1 year.

Note

Additional prior authorization/medical necessity requirements may still apply

Meeting the Drug Quantity Management Program Criteria does not satisfy any other prior authorization or medical necessity requirements; separate authorizations or medical necessity determinations may still be required.

Billing Rule

Use appropriate codes as of the submission effective date

When billing for services, providers must use the most appropriate codes as of the effective date of the submission; reimbursement is not allowed for services billed for conditions or diagnoses not covered under this Coverage Policy.

Denial Risk

Denial risk if billed with non-covered codes

Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.

Quantity Limits by Strength and Dispensing Channel

Olumiant 1 mg — quantity limits

Strength1 mg tablets

Maximum (retail)30 tablets per 30 days

Maximum (home delivery)90 tablets per 90 days

NotesExceptions to quantity limits may be approved for specified diagnoses; any other exception is not medically necessary.

Olumiant 2 mg — quantity limits

Strength2 mg tablets

Maximum (retail)30 tablets per 30 days

Maximum (home delivery)90 tablets per 90 days

NotesExceptions to quantity limits may be approved for specified diagnoses; any other exception is not medically necessary.

Olumiant 4 mg — quantity limits

Strength4 mg tablets

Maximum (retail)30 tablets per 30 days

Maximum (home delivery)90 tablets per 90 days

NotesExceptions to quantity limits may be approved for specified diagnoses; any other exception is not medically necessary.

Olumiant (any strength) — home delivery limits

Applicable strengthsAny strength (1 mg, 2 mg, 4 mg)

Maximum (home delivery)90 tablets per 90 days per strength

Retail comparisonRetail maximum is 30 tablets per 30 days per strength

ExceptionsSpecified diagnoses (AGS, CANDLE/PRAAS, SAVI) may allow override; other exceptions are not medically necessary.

Background

Olumiant (baricitinib) is a Janus kinase (JAK) pathway inhibitor with labeled indications that include alopecia areata, rheumatoid arthritis, and treatment of certain hospitalized adults with COVID-19. Dosing and safety considerations vary by indication, and Olumiant should not be combined with other JAK inhibitors, biologic immunomodulators, or potent immunosuppressants.

For the purposes of this quantity management policy, Olumiant is identified by its tablet strengths—1 mg, 2 mg, and 4 mg—and managed accordingly under the Drug Quantity Management program.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Olumiant Drug Quantity Management Policy - Per Days

Policy CodePolicy DQM019

Change TypeNew policy

Effective DateFeb 15, 2026

Next Review DateN/A

Key ActionEnsure Drug Quantity Management rule is met at point of service; if not met, submit criteria-based request for approval (approvals provided for 1 year).

SourceLink

On This Page

OpenPayer

Inflammatory Conditions - Olumiant Drug Quantity Management Policy - Per Days

Coverage Criteria — Quantity Limits and Exceptions

Provider Actions, Billing & Prior Authorization

Definitions

Quantity Limits by Strength and Dispensing Channel

Background

Revision History