CurrentColorado Rocky Mountain Health PlansPolicy N/A

Anzupgo (delgocitinib) — Prior Authorization / Medical Necessity

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

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAnzupgo (delgocitinib) — Prior Authorization / Medical Necessity

Policy CodePolicy N/A

Change TypeNew program with clinical criteria added

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization documenting diagnosis of moderate to severe chronic hand eczema and trials of a medium‑ to high‑potency topical corticosteroid and a topical calcineurin inhibitor.

SourceLink

POLICY UPDATE CHANGES

New prior authorization/medical necessity program established for Anzupgo (delgocitinib).

Initial and reauthorization clinical criteria, including required prior use of topical corticosteroid and topical calcineurin inhibitor, and prohibitions on concomitant biologic/JAK inhibitor or potent immunosuppressant use.

Authorization duration specified as 12 months.

5/1/2026effective date

3/2026P&T approval

2required prior therapies

12 moauthorization duration

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Anzupgo (delgocitinib)

inv-01: Initial Therapy

Covered when ALL of the following are met:

Initial Authorization: Patient has a diagnosis of moderate to severe chronic hand eczema; AND history of failure, contraindication, or intolerance to both (1) one topical corticosteroid of at least medium- to high-potency and (2) one topical calcineurin inhibitor; AND patient is not receiving Anzupgo in combination with a biologic medication or another JAK inhibitor; AND patient is not receiving Anzupgo in combination with a potent immunosuppressant medication (e.g., azathioprine, cyclosporine); AND prescribed by or in consultation with a Dermatologist or Allergist/Immunologist.

Authorization issued for 12 months.

inv-02: Continuation Therapy

Reauthorization covered when ALL of the following are met:

Reauthorization: Documentation of positive clinical response to Anzupgo therapy; AND patient is not receiving Anzupgo in combination with a biologic medication or another JAK inhibitor; AND patient is not receiving Anzupgo in combination with a potent immunosuppressant medication (e.g., azathioprine, cyclosporine).

Authorization issued for 12 months.

Use of Anzupgo in combination with other systemic Janus kinase (JAK) inhibitors, biologic therapies for eczema/psoriasis, or potent immunosuppressant medications is not recommended and is excluded from approval. The policy specifically lists combinations with agents such as Adbry (tralokinumab-ldrm), Cibinqo (abrocitinib), Dupixent (dupilumab), Ebglyss (lebrikizumab-lbkz), Nemluvio (nemolizumab-ilto), Rinvoq (upadacitinib) as examples of biologic or JAK therapies to avoid, and gives azathioprine and cyclosporine as examples of potent immunosuppressants. Coverage may be denied if Anzupgo is prescribed concomitantly with these agents.

Initial Authorization Requirements

inv-10: Initial Authorization

Initial authorization requirements

Initial Authorization: Diagnosis of moderate to severe chronic hand eczema; AND history of failure, contraindication, or intolerance to both: (1) one topical corticosteroid of at least medium- to high-potency (e.g., mometasone furoate, fluocinolone acetonide, fluocinonide) AND (2) one topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus); AND no concomitant use of Anzupgo with a biologic medication or another JAK inhibitor (e.g., tralokinumab, abrocitinib, dupilumab, lebrikizumab, nemolizumab, upadacitinib); AND no concomitant use of Anzupgo with a potent immunosuppressant (e.g., azathioprine, cyclosporine); AND prescribed by or in consultation with a Dermatologist or Allergist/Immunologist.

Authorize for 12 months if met.

Reauthorization / Continuation Requirements

inv-11: Reauthorization

Reauthorization rules

Reauthorization: Documentation of positive clinical response to Anzupgo; AND no concomitant use of Anzupgo with a biologic medication or another JAK inhibitor (e.g., tralokinumab, abrocitinib, dupilumab, lebrikizumab, nemolizumab, upadacitinib); AND no concomitant use of Anzupgo with a potent immunosuppressant (e.g., azathioprine, cyclosporine).

Authorize for 12 months if met. Prescriptions should be by or in consultation with a Dermatologist or Allergist/Immunologist.

Provider Action & Documentation Requirements

Prior Authorization

Initial authorization requirements

Prior Authorization Required: Anzupgo requires prior authorization. The request must document the diagnosis and prior therapy trials as described below.

Diagnosis: moderate to severe chronic hand eczema
Prescriber: Dermatologist or Allergist/Immunologist (prescribed by or in consultation with)

Step Therapy

Required prior topical therapies

Step therapy — Documented trial and failure, intolerance, or contraindication to the required topical therapies is required before approval.

One topical corticosteroid of at least medium- to high-potency (e.g., mometasone furoate, fluocinolone acetonide, fluocinonide)
One topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus). Note: Elidel and tacrolimus ointment require prior authorization.

Step Therapy Requirements

Required prior topical therapies
Trial of at least one medium- to high‑potency topical corticosteroid (e.g., Elocon [mometasone furoate], Synalar [fluocinolone acetonide], Lidex [fluocinonide]) AND one topical calcineurin inhibitor (e.g., Elidel [pimecrolimus], Protopic [tacrolimus]) documented as failure, contraindication, or intolerance prior to approval.

Definitions

inv-09: Chronic hand eczema (CHE) — definition and applicability to indicated population

TermChronic hand eczema (CHE)

DefinitionA moderate to severe inflammatory condition of the hands for which topical therapies are standard; Anzupgo (delgocitinib) is a topical JAK inhibitor option for adults.

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

Limitations of useNot recommended in combination with other JAK inhibitors or potent immunosuppressants.

Background

Anzupgo (delgocitinib) is a topical Janus kinase (JAK) inhibitor indicated for the treatment of moderate to severe chronic hand eczema in adults with inadequate response to or contraindication/intolerance to topical corticosteroids. The agent provides a topical JAK-targeted mechanism of action for localized inflammatory control on the hands.

Limitations of use include avoidance of concomitant therapy with other systemic JAK inhibitors or potent immunosuppressants. Initial coverage requires documentation of a diagnosis of moderate to severe chronic hand eczema and prior failure, contraindication, or intolerance to both a topical corticosteroid of at least medium- to high‑potency (for example, Elocon, Synalar, Lidex) and a topical calcineurin inhibitor (for example, Elidel, Protopic). Prescribing should be by or in consultation with a Dermatologist or Allergist/Immunologist, and authorization is issued for 12 months when criteria are met.

Quantity Limits and Dispensing

inv-13: Anzupgo (delgocitinib) — supply or quantity limit notes

DrugAnzupgo (delgocitinib)

Quantity/supply noteSupply limits may be in place; follow program-specific limits.

Authorization considerationsNotwithstanding coverage criteria, automated approval or re-approval may occur based on prior claim/medication history and diagnosis codes per program rules.