CurrentColorado Rocky Mountain Health PlansPolicy N/A

Anzupgo (delgocitinib) topical — Coverage Criteria for Chronic Hand Eczema

Prior authorization and medical necessity criteria for coverage of topical Anzupgo (delgocitinib) for adults with moderate to severe chronic hand eczema; governs prescribers and pharmacy/benefit reviewers under Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAnzupgo (delgocitinib) topical — Coverage Criteria for Chronic Hand Eczema

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis plus prior failure, contraindication, or intolerance to required topical therapies before initial approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

adultsindicated population

2 classespre-requisite therapies

P&T 3/2026approval date

Coverage Criteria for Anzupgo (delgocitinib) Topical

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inv-01: Initial Authorization

Covered when ALL of the following are met

Initial Authorization Criteria: a. Diagnosis of moderate to severe chronic hand eczema; AND b. History of failure, contraindication, or intolerance to both of the following topical therapy classes: (1) one topical corticosteroid of at least medium- to high-potency (e.g., Elocon, Synalar, Lidex); and (2) one topical calcineurin inhibitor (e.g., Elidel, Protopic); AND c. Patient is not receiving Anzupgo in combination with a biologic medication or JAK inhibitor (e.g., Adbry, Cibinqo, Dupixent, Ebglyss, Nemluvio, Rinvoq); AND d. Patient is not receiving Anzupgo in combination with a potent immunosuppressant medication (e.g., azathioprine, cyclosporine); AND e. Prescribed by or in consultation with a Dermatologist or Allergist/Immunologist.

Examples of corticosteroids and calcineurin inhibitors are provided in the policy; Elidel and tacrolimus ointment require prior authorization.

inv-02: Reauthorization

Covered when ALL of the following are met

Reauthorization Criteria: a. Documentation of positive clinical response to Anzupgo therapy; AND b. Patient is not receiving Anzupgo in combination with a biologic medication or JAK inhibitor (e.g., Adbry, Cibinqo, Dupixent, Ebglyss, Nemluvio, Rinvoq); AND c. Patient is not receiving Anzupgo in combination with a potent immunosuppressant medication (e.g., azathioprine, cyclosporine).

Authorization will be issued for 12 months; state mandates and member benefit plans may also impact coverage.

Use of Anzupgo in combination with other JAK inhibitors or with potent immunosuppressants is not recommended.

Initial Therapy

inv-10: Initial Therapy

Initial coverage criteria

Initial Therapy: Diagnosis of moderate to severe chronic hand eczema; prior failure, contraindication, or intolerance to both: one topical corticosteroid of at least medium- to high-potency and one topical calcineurin inhibitor; not used concomitantly with biologic medications or JAK inhibitors; not used concomitantly with potent immunosuppressant medications; prescribed by or in consultation with a Dermatologist or Allergist/Immunologist.

Examples of agents provided in policy (e.g., Elocon, Synalar, Lidex, Elidel, Protopic).

Continuation / Reauthorization Criteria

inv-11: Continuation Therapy

Reauthorization/continuation rules

Reauthorization: Must document positive clinical response to continue Anzupgo; continued non-concomitance with biologic medications or JAK inhibitors and with potent immunosuppressant medications is required.

Reauthorization/authorization will be issued for 12 months; state mandates and member benefit plans may also impact coverage.

Step Therapy Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required before initiation of therapy.

Authorization will be issued for 12 months.
State mandates and member-specific benefit plans may affect coverage. Federal regulatory requirements and other policies/utilization management programs may apply.

Step Requirement	Required Trial
One topical corticosteroid of at least medium- to high-potency (e.g., Elocon [mometasone furoate], Synalar [fluocinolone acetonide], Lidex [fluocinonide])
One topical calcineurin inhibitor (e.g., Elidel [pimecrolimus], Protopic [tacrolimus])

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization required — initial criteria must all be met

Prior authorization is required. Initial approval is granted only when all initial authorization criteria are met, including a diagnosis of moderate to severe chronic hand eczema, required prior therapy failures/contraindications/intolerances, avoidance of concomitant biologic/JAK inhibitor or potent immunosuppressant use, and prescription by or in consultation with a Dermatologist or Allergist/Immunologist.

Diagnosis of moderate to severe chronic hand eczema must be documented
Prescribed by or in consultation with a Dermatologist or Allergist/Immunologist

Documentation Required

Required documentation for authorization and reauthorization

Documentation must include the diagnosis of moderate to severe chronic hand eczema, prior treatment history showing failure, contraindication, or intolerance to one medium- to high-potency topical corticosteroid and one topical calcineurin inhibitor, and for reauthorization evidence of positive clinical response; prescription should be by or in consultation with a Dermatologist or Allergist/Immunologist.

Record of specific agents/classes tried and reasons for failure/intolerance/contraindication
For reauthorization, documentation of positive clinical response to Anzupgo

Denial Risk

Denial triggers — missing diagnosis or prior therapy documentation

Requests may be denied if there is no documented diagnosis of moderate to severe chronic hand eczema or if there is no documentation of failure, contraindication, or intolerance to both a medium- to high-potency topical corticosteroid and a topical calcineurin inhibitor.

Also a denial risk if patient is receiving Anzupgo with a biologic/JAK inhibitor or a potent immunosuppressant
Denial likely if prescription is not by or in consultation with an appropriate specialist

Definitions

Chronic hand eczema (CHE) — definition

DefinitionA persistent inflammatory skin condition affecting the hands; in this policy the term refers to moderate to severe disease for which topical Anzupgo (delgocitinib) is indicated.

Indicated populationAdults with moderate to severe chronic hand eczema who have had an inadequate response to, or for whom topical corticosteroids are not advisable.

Limitation of useUse of Anzupgo in combination with other JAK inhibitors or potent immunosuppressants is not recommended.

Related drug classTopical Janus kinase (JAK) inhibitor (delgocitinib).