Cigna Olumiant Prior Auth Policy Update

Coverage Criteria for Olumiant (baricitinib)

inv-01: Alopecia Areata - Initial Therapy

Approve for alopecia areata when ALL of the following are met

Alopecia Areata - Initial Therapy: i. Patient is ≥ 18 years of age; AND ii. Current episode of alopecia areata lasting ≥ 6 months; AND iii. ≥ 50% scalp hair loss; AND iv. Patient has tried at least one of the following: a) conventional systemic therapy (examples include corticosteroids, methotrexate, cyclosporine) OR b) high- or super-high potency topical corticosteroid (exception to the requirement for a trial of one conventional systemic agent if patient has previously tried Leqselvi [deuruxolitinib] or Litfulo [ritlecitinib]); AND v. Medication is prescribed by or in consultation with a dermatologist.

Initial approval = 6 months

inv-02: Alopecia Areata - Continuation

Approve for patients currently receiving Olumiant when ALL of the following are met

Alopecia Areata - Continuation: i. Patient is ≥ 18 years of age; AND ii. Patient has been established on the requested drug for at least 6 months; AND iii. Patient experienced a beneficial clinical response, defined as improvement from baseline in extent and density of scalp hair loss; AND iv. According to the prescriber, the patient continues to require systemic therapy for alopecia areata.

Continuation approval = 1 year

inv-03: Rheumatoid Arthritis - Initial Therapy

Approve for rheumatoid arthritis when ALL of the following are met

Rheumatoid Arthritis - Initial Therapy: i. Patient is ≥ 18 years of age; AND ii. Patient has had a 3-month trial of at least one tumor necrosis factor (TNF) inhibitor OR has tried at least one TNF inhibitor but was unable to tolerate a 3-month trial (conventional synthetic DMARDs such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine do NOT count); AND iii. Medication is prescribed by or in consultation with a rheumatologist.

Initial approval = 6 months

inv-04: Rheumatoid Arthritis - Continuation

Approve for patients currently receiving Olumiant for RA when ALL of the following are met

Rheumatoid Arthritis - Continuation: i. Patient has been established on the requested drug for at least 6 months; AND ii. Patient experienced a beneficial clinical response as evidenced by ONE of the following: a) improvement by at least one standardized objective disease activity measure (e.g., CDAI, DAS28-ESR/CRP, PAS-II, RAPID-3, SDAI); OR b) improvement in at least one symptom such as decreased joint pain, decreased morning stiffness, improved function or activities of daily living, or decreased soft tissue swelling.

Continuation approval = 1 year

inv-05: Type 1 Interferonopathy (Other Uses with Supportive Evidence)

Approve for Type 1 interferonopathy when ALL of the following are met

Type 1 Interferonopathy (Other Uses with Supportive Evidence): A) Patient has ONE of the following: i) Aicardi-Goutieres syndrome (AGS); OR ii) CANDLE/PRAAS; OR iii) SAVI; AND B) Diagnosis is established by a molecular genetic test demonstrating a pathogenic variant in a gene associated with AGS, CANDLE/PRAAS, or SAVI (examples of genes listed in policy); AND C) Medication is prescribed by or in consultation with a geneticist, rheumatologist, immunologist, neurologist, or a physician who specializes in type 1 interferonopathies.

Approval = 1 year

Olumiant (baricitinib) is considered not medically necessary for any use not explicitly listed in this policy. This includes, but is not limited to, concurrent administration with other biologic agents, concurrent use with another targeted synthetic oral small molecule drug for inflammatory conditions, use together with topical JAK inhibitors, or co-administration with other potent immunosuppressants (e.g., azathioprine, cyclosporine). These combinations are not recommended because of the potential for increased adverse events and a lack of controlled clinical data demonstrating added benefit. (This policy does not restrict co‑administration with conventional synthetic DMARDs such as methotrexate when supported by evidence.)

Concurrent administration of Olumiant with a biologic immunomodulator or with another targeted synthetic oral small molecule used to treat inflammatory conditions is prohibited under this policy and is considered not medically necessary. Examples of biologic agents cited in the policy include products such as Adbry (tralokinumab), Dupixent (dupilumab), Ebglyss (lebrikizumab), Nemluvio (nemolizumab), Fasenra (benralizumab), Nucala (mepolizumab), Tezspire (tezepelumab), and Xolair (omalizumab). The policy also disallows combining Olumiant with topical JAK inhibitors (e.g., ruxolitinib cream) or other potent immunosuppressants because of additive immunosuppression risk and limited evidence for additive efficacy.

Initial Therapy Requirements and Step Therapy

inv-21: Initial therapy

Initial therapy criteria and required prior trials

Initial therapy - General Requirements: Prior authorization is required. For alopecia areata: patient ≥ 18 years, current episode ≥ 6 months, ≥ 50% scalp hair loss, trial of at least one conventional systemic therapy or a high-/super-high potency topical corticosteroid (exceptions if prior Leqselvi or Litfulo), and prescribed by or in consultation with a dermatologist. For rheumatoid arthritis: patient ≥ 18 years, documentation of a 3-month trial of at least one TNF inhibitor (or inability to tolerate a 3-month trial after trying one), conventional synthetic DMARDs do not count, and prescribed by or in consultation with a rheumatologist.

Initial approval typically 6 months

Step	Requirement	Duration / Notes
1	Trial of at least one tumor necrosis factor (TNF) inhibitor for 3 months OR documentation that patient tried a TNF inhibitor but was unable to tolerate a 3-month trial	Initial approval reviewed under RA initial therapy criteria; conventional synthetic DMARDs (e.g., methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) do not count toward the TNF inhibitor requirement; medication must be prescribed by or in consultation with a rheumatologist

Continuation Therapy and Renewal Requirements

Prior Authorization

Continuation Therapy and Renewal Requirements

Prior authorization is required. See Appendix: Prior Authorization for the list of product names, formulations, and specific prior authorization requirements. Providers must not prescribe Olumiant (baricitinib) in combination with other JAK inhibitors or with biologic immunomodulators listed as prohibited combinations in the Appendix. If a product or formulation is not listed in the Appendix, the Appendix provisions are not applicable to that product.

Appendix cross-reference: Prior Authorization — providers must reference the Appendix for the approved product names, dosing formulations, and any prior authorization form codes required at the time of request.
Prohibited combinations — Olumiant must not be used concomitantly with other JAK inhibitors or with biologic disease-modifying antirheumatic drugs (bDMARDs) as listed in the Appendix; requests that indicate use with prohibited agents will be denied.
Not applicable content in Appendix — if a requested product, formulation, or combination is not listed in the Appendix, the Appendix-specific restrictions and prior-authorization codes do not apply; standard policy criteria still apply.
Prior therapy and prescriber specialty documentation — for continuation approvals, providers must document: patient age, duration of disease, prior therapy trials (agents, doses, dates, and reason for discontinuation if applicable), and that the prescriber is the required specialist or the request is in consultation with the required specialist (see indication-specific criteria for specialty requirements).

Provider Actions, Authorization, and Documentation

Prior Authorization

Obtain prior authorization — approvals are time-limited

Prior authorization is required for Olumiant; approvals are time-limited and specified by indication (initial approvals commonly 6 months; continuation or established therapy approvals commonly 1 year).

Initial approvals for alopecia areata and rheumatoid arthritis are for 6 months when criteria are met (see respective initial therapy criteria).
Continuation/established therapy approvals (including Type 1 interferonopathy) are authorized for 1 year when continuation criteria are met.

Step Therapy

Document 3-month TNF inhibitor trial (RA) or intolerance

For rheumatoid arthritis initial approval, documentation must show a 3-month trial of at least one tumor necrosis factor (TNF) inhibitor or documentation of inability to tolerate a 3-month trial of a TNF inhibitor prior to authorizing Olumiant.

Conventional synthetic DMARDs (e.g., methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) do not fulfill the TNF inhibitor trial requirement.
Refer to the Appendix for examples of TNF inhibitors used for RA.

Step Therapy Tables and Grouping

Step	Requirement	Exception / Prescriber
1	Patient must have trialed at least one TNF inhibitor (3-month trial) prior to initiation of Olumiant for rheumatoid arthritis	Exception: documented intolerance or inability to complete a 3-month trial substitutes; Olumiant must be prescribed by or in consultation with a rheumatologist

Group	Included oral targeted small molecule drugs (examples)	Implication
Oral targeted small molecule / JAK and other TSOM drugs	Apremilast (Otezla, Otezla XR); Deucravacitinib (Sotyktu); Abrocitinib (Cibinqo); Baricitinib (Olumiant); Ritlecitinib (Litfulo); Deuruxolitinib (Leqselvi); Upadacitinib (Rinvoq, Rinvoq LQ); Tofacitinib (Xeljanz, Xeljanz XR); others listed in appendix	Appendix groups these oral agents together, implying therapeutic interchangeability or consideration within the same class for step/alternative therapy decisions (no explicit interchange rules provided)

Definitions and Example Therapies

Conventional systemic therapies — examples

DefinitionConventional systemic therapies used as examples for alopecia areata include corticosteroids, methotrexate, and cyclosporine.

Role in step therapyA prior trial of at least one conventional systemic therapy (or high-/super-high potency topical corticosteroid) is required before initial approval for alopecia areata unless exception applies.

Combination guidanceConventional synthetic DMARDs (e.g., methotrexate) are not excluded from concurrent use with Olumiant per policy notes.

JAK inhibitors — examples

DefinitionJAK inhibitors are oral small molecule drugs that inhibit Janus kinase signaling pathways; examples listed in the appendix include Olumiant (baricitinib), Rinvoq (upadacitinib), Xeljanz (tofacitinib), Cibinqo (abrocitinib), Litfulo (ritlecitinib), Leqselvi (deuruxolitinib), and others.

Background on Olumiant

Olumiant (baricitinib) is an oral Janus kinase (JAK) inhibitor used across multiple inflammatory conditions. Covered indications in this policy include: alopecia areata (adults with severe disease meeting specific criteria), rheumatoid arthritis (adults with moderate to severe active disease after inadequate response to tumor necrosis factor inhibitors), and select Type 1 interferonopathies (e.g., AGS, CANDLE/PRAAS, SAVI) when the diagnosis is confirmed by molecular genetic testing and care is provided or coordinated by an appropriate specialist. Prior authorization is required for Olumiant; initial approvals are commonly limited to 6 months with continuation approvals and some other indications limited to 1 year. The policy emphasizes that Olumiant should not be combined with other biologics, other targeted synthetic oral small molecules for inflammatory conditions, topical JAK inhibitors, or other potent immunosuppressants due to additive immunosuppression risk and limited evidence of added benefit.

Coding, Appendix Products, and Related References

Note

Appendix identifies Olumiant among JAK inhibitors — use as cross-reference only

Appendix cross-reference reiterates Olumiant is listed among JAK inhibitors and shows related agents, but the appendix listing alone does not establish PA criteria or coverage rules.

Appendix line: Olumiant (baricitinib tablets) — Inhibition of JAK pathways; examples include indications AA and RA.
Appendix groups Olumiant with other JAK inhibitors (Rinvoq, Xeljanz, Litfulo, Leqselvi, etc.) for reference.

Note

Appendix enumerates oral small molecule drugs for reference

The Appendix groups and enumerates oral small molecule drugs (e.g., apremilast, deucravacitinib, abrocitinib, baricitinib, ritlecitinib, deuruxolitinib, upadacitinib, tofacitinib) for reference when considering therapeutic alternatives or class membership.

Appendix entries list Otezla (apremilast), Sotyktu (deucravacitinib), Cibinqo (abrocitinib), Olumiant (baricitinib), Litfulo (ritlecitinib), Leqselvi (deuruxolitinib), Rinvoq (upadacitinib), Xeljanz (tofacitinib), etc.
These listings inform class-based considerations such as step therapy or alternative therapies but do not themselves impose step rules.

Policy Revision History and Material Changes

2026-05-15policy_effective_dateLatest

Policy effective date updated (administrative effective/processing noted in revision history).

2026-04-30clarification

Administrative update recorded with no clinical criteria changes noted in the policy revision history.

2026-02-01appendix_update

OpenPayer

Olumiant Prior Authorization Policy

Coverage Criteria for Olumiant (baricitinib)

Initial Therapy Requirements and Step Therapy

Continuation Therapy and Renewal Requirements

Provider Actions, Authorization, and Documentation

Step Therapy Tables and Grouping

Definitions and Example Therapies

Background on Olumiant

Coding, Appendix Products, and Related References

Policy Revision History and Material Changes