CurrentColorado Rocky Mountain Health PlansPolicy 2025 P 2200-12

Olumiant® (baricitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Prior authorization and medical necessity criteria for Olumiant (baricitinib) for UnitedHealthcare Commercial Plans, covering indications for moderately to severely active rheumatoid arthritis (RA) and severe alopecia areata (AA), with initial and reauthorization requirements, restrictions on concomitant therapies, prescriber specialty requirements, and authorization duration.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOlumiant® (baricitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2025 P 2200-12

Change TypeCoverage criteria updates & step therapy revisions

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must obtain prior authorization for Olumiant and document required criteria (diagnosis, prior therapy trials or claims/medical records, dates and durations) to be approved for 12 months.

SourceLink

POLICY UPDATE CHANGES

Effective date set to 6/1/2025 and program number assigned (2025 P 2200-12).

Added coverage criteria for alopecia areata (AA).

Updated RA step requirement to require failure/contraindication/intolerance to two preferred products and clarified preferred adalimumab products.

Updated not receiving in combination language to 'targeted immunomodulator' and updated examples, including Litfulo for AA.

Removed prescriber requirement from reauthorization criteria (historical change).

2Covered Indications

12 mo

Authorization Duration

>=50%AA severity threshold

3 moDMARD trial length (RA)

Coverage Summary

Scope: Prior authorization and medical necessity criteria for Olumiant (baricitinib) for UnitedHealthcare Commercial Plans covering 2 covered indications — moderately to severely active rheumatoid arthritis (RA) and severe alopecia areata (AA) — with initial and reauthorization requirements. Coverage stance: covered_with_criteria. Authorization duration: 12 months for initial approvals and reauthorizations. High-level restrictions: therapy not recommended/covered in combination with other JAK inhibitors, biologic DMARDs/targeted immunomodulators, or potent immunosuppressants (e.g., azathioprine, cyclosporine). Effective date: 2025-06-01; last review: 2025-04-01; policy number: 2025 P 2200-12.

Key thresholds and quick facts

Authorization Duration12 months

AA severity threshold>=50% scalp hair loss

DMARD trial duration3 months

Covered Indications2

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Unproven / Exclusions

Exclusion-style language: Olumiant is not to be used in combination with other JAK inhibitors, biologic DMARDs/targeted immunomodulators, or potent immunosuppressants. The criteria explicitly deny approval when the patient is receiving Olumiant in combination with a Targeted immunomodulator (examples: Enbrel, Cimzia, Simponi, Orencia, adalimumab, Xeljanz, Rinvoq, and for AA examples include Litfulo/ritlecitinib) or a Potent immunosuppressant (e.g., azathioprine or cyclosporine). Definitions: Targeted immunomodulator includes biologic DMARDs and targeted synthetic DMARDs such as etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib, ritlecitinib; Potent immunosuppressant examples include azathioprine and cyclosporine.

Applicable Codes

Example targeted immunomodulators / comparators listed in criteria (informational)mixed

	Enbrel (etanercept) - listed as example targeted immunomodulator
	Cimzia (certolizumab) - listed as example targeted immunomodulator
	Simponi (golimumab) - listed as example targeted immunomodulator
	Orencia (abatacept) - listed as example targeted immunomodulator
	adalimumab - listed as example targeted immunomodulator / preferred adalimumab products referenced
	Xeljanz (tofacitinib) - listed as example targeted immunomodulator
	Rinvoq (upadacitinib) - listed as example targeted immunomodulator
	Litfulo (ritlecitinib) - listed as example not to be used in combination (AA)

Example targeted immunomodulators / comparators listed in criteria (informational)mixed

No codes listed

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required for Olumiant (baricitinib). Document that the member meets the applicable clinical criteria for the requested indication. Approvals will be issued for 12 months.

Required documentation elements: diagnosis, and documentation of prior therapy trials or claims including drug name, dates, and duration of trial (or submission of claims/medical records).
Approvals issued for 12 months.

Documentation Required

Document prior therapy trials or claims

For initial rheumatoid arthritis (RA) approvals, document either a 3-month trial of a non-biologic DMARD at maximally indicated doses or prior treatment with a targeted immunomodulator. Evidence may be provided via claims history or submission of medical records. Include drug name, dates, and duration of therapy for each trial.

Clinical Evidence & References

Evidence and approvals: P&T approval history spans 5/2020 through 4/2025. Key references cited in the policy include the Product label (June 2022), the ACR rheumatoid arthritis guideline (2021), the NEJM BRAVE‑AA trials (2022), and the British Association of Dermatologists guidelines (2012).

Background

Background: Olumiant (baricitinib) is a Janus Kinase (JAK) inhibitor indicated by label for moderately to severely active rheumatoid arthritis and for severe alopecia areata; it is also indicated in certain hospitalized patients with COVID-19. The policy recommends against combining Olumiant with other JAK inhibitors, biologic DMARDs/targeted immunomodulators, or potent immunosuppressants. Definitions included in the policy: Targeted immunomodulator — includes biologic DMARDs and targeted synthetic DMARDs such as etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib, ritlecitinib; Potent immunosuppressant — examples include azathioprine and cyclosporine.

Revision History

2025-06-01addedLatest

Effective date set to 6/1/2025 and program number assigned (2025 P 2200-12).

4/2025revised

Updated RA step requirement noting removal of adalimumab examples and directing to drug coverage tools for preferred product list; clinical intent unchanged.

10/2024revised

Updated RA step requirement to clarify preferred adalimumab products (Adalimumab-adaz, Amjevita for Nuvaila, Humira); clinical intent unchanged.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOlumiant® (baricitinib) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2025 P 2200-12

Change TypeCoverage criteria updates & step therapy revisions

Effective DateJun 1, 2025

Next Review Date

SourceLink

On This Page

Acceptable documentation: pharmacy claims history, medical record notes, medication administration records, or clinic documentation listing drug/date/duration.
For Connecticut, Kentucky and Mississippi business a 30-day trial of a non-biologic DMARD may be acceptable per state-specific footnote.

Step Therapy

Step requirement for RA

Step requirement for RA: member must have failed, have a contraindication to, or be intolerant of two preferred products unless applicable bypass criteria are met. See drug coverage tools for the current list of preferred adalimumab products and other preferred agents.

Preferred products include (examples listed in policy): adalimumab preferred products (see drug coverage tools), Cimzia, Enbrel, Rinvoq, Simponi, Xeljanz/Xeljanz XR.
Bypass pathways may allow coverage based on prior targeted immunomodulator use or documented current therapy when claims are available.

Documentation Required

Avoid concomitant therapies

Avoid concomitant therapies: ensure the patient is not receiving Olumiant in combination with other targeted immunomodulators, other JAK inhibitors, biologic DMARDs, or potent immunosuppressants. Combination therapy with other JAK inhibitors or biologic DMARDs is not recommended.

Examples of targeted immunomodulators/biologic DMARDs and JAK inhibitors: Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Rinvoq (upadacitinib), Litfulo (ritlecitinib).
Examples of potent immunosuppressants: azathioprine, cyclosporine.

Billing Rule

Authorization length

Authorization length: Authorization will be issued for 12 months for both initial approvals and reauthorizations.

Documentation Required

Prescriber specialty requirement

Prescriber specialty requirement: initial RA prescriptions must be by or in consultation with a rheumatologist. Initial alopecia areata (AA) prescriptions must be by or in consultation with a dermatologist.

Documentation Required

Document positive clinical response for reauthorization

For reauthorization, document a positive clinical response to Olumiant therapy (for example, clinician assessment of symptom improvement, objective measures recorded in the medical record, or other clinical documentation demonstrating therapeutic benefit). Also confirm the patient is not receiving Olumiant in combination with targeted immunomodulators or potent immunosuppressants. Approvals for reauthorization will be issued for 12 months.

Acceptable evidence of positive clinical response: provider progress notes, disease activity scores, photographic documentation for alopecia areata, or other objective clinical measures documented in the medical record.

2/2024revised

Revised RA step requirement to require failure/contraindication/intolerance to two preferred products and added adalimumab preferred product footnote; clinical intent unchanged.

8/2022added

Added coverage criteria for alopecia areata (AA) including requirement for >=50% scalp hair loss and prescriber specialty.

7/2023revised

Updated 'not receiving in combination' language to 'targeted immunomodulator' and updated examples (including later addition of Litfulo as an example not to be used in combination).

6/2021removed

Removed prescriber requirement from reauthorization criteria (historical change).

5/2020 through 4/2025other

P&T approval history recorded through 4/2025 (P&T approval dates: 5/2020, 5/2021, 6/2021, 12/2021, 2/2022, 8/2022, 7/2023, 9/2023, 11/2023, 2/2024, 10/2024, 4/2025).