CurrentCignaPolicy N/A

Olumiant (baricitinib) — Drug Quantity Management (Coverage Criteria)

Defines quantity limits and medical-necessity exceptions for Olumiant (baricitinib) tablets for Cigna-administered health benefit plans and describes approval duration and affected supply types.

Policy Summary

PayerCigna

PolicyOlumiant (baricitinib) — Drug Quantity Management (Coverage Criteria)

Policy CodePolicy N/A

Change TypeAdded diagnosis-based exceptions to quantity limits

Effective Date

Next Review DateDec 3, 2025

Key ActionSubmit prior authorization with supporting diagnosis documentation to request an exception when a requested quantity exceeds the stated drug quantity limits.

SourceLink

POLICY UPDATE CHANGES

New exceptions to the standard quantity limits were added for Aicardi-Goutières syndrome (AGS), CANDLE/PRAAS, and SAVI.

30Retail max per 30 days

90Home delivery max per 90 days

1 yrApproval duration

1,2,4 mgTablet strengths

Coverage Criteria

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Medical-necessity exceptions (Interferonopathies)

Quantity limits for Olumiant are covered except when ALL of the following diagnosis-based criteria are met:

Exception criteria for quantity limits: Approve the requested quantity for a 30-day retail supply and a 90-day home delivery supply 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 present

Approvals provided for 1 year.

Any exception to the stated Drug Quantity Limits for Olumiant (baricitinib) other than the specific interferonopathy diagnoses listed in this policy is considered not medically necessary.

Requests for quantities that exceed the stated retail (30 tablets per 30 days) or home delivery (90 tablets per 90 days) limits that do not meet one of the listed diagnosis-based exceptions are considered not medically necessary.

Coding and Supply Limits

Drug supply/coding notesNDC

NDCs not specified

No NDCs provided in document; strengths and supply quantities specified.

Retail supply limit

Retail supply limit30 tablets per 30 days

Applies to all tablet strengths1 mg, 2 mg, 4 mg

Effect on claimsClaims exceeding this retail 30-day limit will be denied unless an exception is granted

Home delivery supply limit

Home delivery supply limit90 tablets per 90 days

Applies to all tablet strengths1 mg, 2 mg, 4 mg

Effect on claimsClaims exceeding this home delivery 90-day limit will be denied unless an exception is granted

Provider Actions and Operational Notes

Denial Risk

Quantity limit denial risk

Claims submitted that exceed the Retail Maximum Quantity Per 30 Days or the Home Delivery Maximum Quantity Per 90 Days will be denied unless a quantity limit exception has been approved per the criteria.

Retail limit: 30 tablets per 30 days
Home delivery limit: 90 tablets per 90 days

Documentation Required

Approval duration and documentation

Approvals granted under this Drug Quantity Management program are issued for a 1 year duration. For requests that exceed the stated quantity limits, documentation supporting a covered exception (per the Criteria, e.g., diagnosis of AGS, CANDLE/PRAAS, or SAVI) must be provided at the time of review to substantiate medical necessity.

All approvals = 1 year
Exceptions require clinical documentation supporting the condition and requested quantity

Prior Authorization

Prior authorization required for excess quantity

Prior authorization is required when the requested quantity exceeds the Drug Quantity Limits; exceptions are approved only when the documented clinical criteria are met.

Requesting quantity > Retail or Home Delivery limits triggers prior authorization

Note

Therapy context and indication documentation

Use the clinical context of the indication when requesting exceptions — for example, rheumatoid arthritis approvals generally require prior TNF‑inhibitor history per the indication context; rare genetic or autoinflammatory diagnoses (e.g., AGS, CANDLE/PRAAS, SAVI) meet exception criteria when documented.

Therapy context (e.g., RA with TNF inhibitor history) should be included in request
Documented diagnoses listed in criteria support exception approval

Background

Olumiant (baricitinib) is an oral Janus kinase (JAK) inhibitor approved for multiple inflammatory conditions referenced in this policy, including rheumatoid arthritis, alopecia areata, and hospitalized COVID-19; dosing varies by indication (for example, rheumatoid arthritis is commonly treated with 2 mg once daily). The Drug Quantity Management program in this policy sets standard quantity limits by supply type and strength while defining limited diagnosis-based exceptions for select interferonopathies.

For the purposes of quantity management, Olumiant is available in 1 mg, 2 mg, and 4 mg tablet strengths and the policy specifies maximum retail and home delivery supplies. Prior authorization is required when a requested quantity exceeds these Drug Quantity Limits; exceptions are approved as medically necessary only when the explicit diagnostic criteria are met and approvals are provided for a duration of 1 year.

Initial Therapy Criteria

Dosing

Dosing guidance by indication

Dosing guidance: Rheumatoid arthritis: 2 mg once daily (QD). COVID-19 (hospitalized adults): 4 mg QD for up to 14 days or until hospital discharge (policy does not target this indication). Crohn's disease: 2 mg QD with increase to 4 mg QD if response is inadequate. For patients with complete or nearly complete scalp hair loss (alopecia areata), consider 4 mg QD; once adequate response is achieved on 4 mg, decrease to 2 mg QD.per indication

Policy notes dosing varies by indication; RA dosing reflects labeled recommendation.

Continuation and Approval Duration

Approval duration

Approval duration for covered exceptions

Continuation approvals: All approvals, including approved exceptions to quantity limits, are provided for a duration of 1 year and may be renewed per policy rules.1 year

Document the diagnosis that supports the exception and the supply quantity requested.

Step	Therapy context / requirement	Notes
1
Clinical context: For rheumatoid arthritis, Olumiant is indicated for adults with moderate to severe active disease who have had an inadequate response to one or more tumor necrosis factor (TNF) inhibitors.
Policy does not impose additional step edits beyond the indication-based expectation of prior TNF inhibitor failure.