CurrentColorado Rocky Mountain Health PlansPolicy 2025 P 2200-12

Olumiant (baricitinib) prior authorization / medical necessity

Criteria for initial and reauthorization coverage of Olumiant (baricitinib) for rheumatoid arthritis and severe alopecia areata, and program operational notes for prescribers and payers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOlumiant (baricitinib) prior authorization / medical necessity

Policy CodePolicy 2025 P 2200-12

Change TypeMaterial updates to AA criteria and RA step therapy requirements

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documented diagnosis, prior therapy details, and prescriber specialty per indication.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for alopecia areata.

Updated criteria to require failure, contraindication or intolerance to two preferred products for RA, removing failure of TNF or needle-phobia.

Updated RA step requirement noting specific preferred adalimumab products and removed preferred adalimumab footnote.

Updated 'not receiving in combination' language to 'targeted immunomodulator' with updated examples.

2covered indications

12 monthsauth duration

specialty requiredprescriber requirement

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Coverage Criteria

Initial Therapy (Rheumatoid Arthritis)"},{

Initial authorization for rheumatoid arthritis — Covered when ALL of the following are met

RA initial authorization: Patient has diagnosis of moderately to severely active rheumatoid arthritis

Prior therapy requirement: Either: (a) history of failure to a 3‑month trial of one non‑biologic DMARD at maximally indicated doses unless contraindicated or (b) prior treatment with a targeted immunomodulator as documented by claims history or medical records (document drug, date, and duration)

Preferred product requirement: Either: (a) history of failure, contraindication, or intolerance to two preferred products (document drug, date, and duration), OR (b) patient is currently on Olumiant therapy documented by claims or medical records (manufacturer samples or Eli Lilly assistance program do not establish current use)

Combination therapy exclusion: Patient is not receiving Olumiant in combination with a targeted immunomodulator (e.g., etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib) or a potent immunosuppressant (e.g., azathioprine, cyclosporine)

Prescriber requirement: Prescribed by or in consultation with a rheumatologist

Reauthorization (Rheumatoid Arthritis)"},{

Reauthorization for rheumatoid arthritis — Covered when ALL of the following are met

Clinical response: Documentation of positive clinical response to Olumiant therapy

Initial Therapy (Severe Alopecia Areata)"},{

Initial authorization for severe alopecia areata — Covered when ALL of the following are met

Diagnosis: Patient has diagnosis of severe alopecia areata

Rule out other causes: Other causes of hair loss have been ruled out (e.g., androgenetic alopecia, cicatricial alopecias, secondary syphilis, tinea capitis, triangular alopecia, trichotillomania)

Severity threshold: Current episode of alopecia areata with at least 50% scalp hair loss>=50% scalp hair loss

Combination therapy exclusion: Patient is not receiving Olumiant in combination with a targeted immunomodulator (e.g., etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib, ritlecitinib) or a potent immunosuppressant (e.g., azathioprine, cyclosporine)

Reauthorization (Severe Alopecia Areata)"},{

Reauthorization for severe alopecia areata — Covered when ALL of the following are met

Clinical response: Documentation of positive clinical response to Olumiant therapy

Combination therapy exclusion: Patient is not receiving Olumiant in combination with a targeted immunomodulator (e.g., etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib, ritlecitinib) or a potent immunosuppressant (e.g., azathioprine, cyclosporine)

Use of Olumiant in combination with other JAK inhibitors, biologic DMARDs/targeted immunomodulators, or potent immunosuppressants is not permitted. Examples of targeted immunomodulators include Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Rinvoq (upadacitinib), and (for alopecia areata) Litfulo (ritlecitinib). Potent immunosuppressant examples include azathioprine and cyclosporine.

Requests must document that the patient is not receiving Olumiant in combination with any of the disallowed agents listed above; for rheumatoid arthritis this combination exclusion is an explicit element of initial and reauthorization criteria and the prescription must be by or in consultation with a rheumatologist, and for alopecia areata the prescription must be by or in consultation with a dermatologist.

Concurrent use of Olumiant with other JAK inhibitors or with biologic DMARDs/targeted immunomodulators is not recommended and does not meet coverage criteria. The policy explicitly states that combinations with other JAK inhibitors or biologic DMARDs are not permitted and such requests would be considered not medically necessary.

Providers should not initiate or continue Olumiant when the patient is receiving any concurrent JAK inhibitor or biologic DMARD; applicable examples include the agents listed in the policy (e.g., etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib, and ritlecitinib).

Initial Therapy

Initial Therapy"},{

Initial authorization criteria differ by indication (RA vs AA) — see detailed criteria.

RA initial: See 'Initial Therapy (Rheumatoid Arthritis)' criteria set

AA initial: See 'Initial Therapy (Severe Alopecia Areata)' criteria set

Step	Requirement	Notes
1	Prior trial of one non-biologic DMARD for 3 months at maximally indicated doses unless contraindicated or intolerant	Examples of non-biologic DMARDs: methotrexate, leflunomide, sulfasalazine, hydroxychloroquine; document drug, date, and duration of trial
1 (alternative)	Prior treatment with a targeted immunomodulator FDA‑approved for RA	Document prior targeted immunomodulator therapy by claims history or medical records; examples include etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib
2	History of failure, contraindication, or intolerance to two preferred products	Preferred product list includes (but not limited to) adalimumab products, certolizumab, etanercept, upadacitinib, golimumab, tofacitinib; document drug, date, and duration of trials
Alternative to step 2	Patient currently on Olumiant with documentation	Claims history or medical records must document current Olumiant therapy; manufacturer samples or assistance programs do not qualify to establish use
Combination therapy exclusion	Patient must not be receiving Olumiant in combination with a targeted immunomodulator or a potent immunosuppressant	Examples of targeted immunomodulators and policy changes/notes available in references; document compliance

Reauthorization / Continuation Therapy

Reauthorization / Continuation Therapy"}]}{

Reauthorization rules require documentation of positive clinical response and continued avoidance of disallowed combinations.

Reauthorization conditions: Documentation of positive clinical response to Olumiant; patient is not receiving Olumiant in combination with a targeted immunomodulator or a potent immunosuppressant

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required for Olumiant for rheumatoid arthritis (RA) and severe alopecia areata. Requests must meet the listed clinical criteria; see criteria sets for Initial Authorization and Continuation Therapy.

Policy Number: 2025 P 2200-12
Effective Date: 2025-06-01

Step Therapy

RA Step-Therapy and Prior Treatment Documentation

For RA initial approval, require documentation of one of the following prior treatments: a 3-month trial of a non-biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses unless contraindicated or intolerant, OR prior treatment with a targeted immunomodulator FDA‑approved for RA (document drug, date, and duration). Additionally, require failure/contraindication/intolerance to two preferred products (document drug, date, and duration) unless the patient meets the alternative current‑use pathway.

Non-biologic DMARD trial: document drug, start/stop dates, and duration (>= 3 months) or reason for discontinuation

Definitions

Targeted immunomodulator — examples

DefinitionTargeted immunomodulator — examples include TNF inhibitors and other biologic or targeted synthetic DMARDs (e.g., etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, upadacitinib).

Class examplesTNF inhibitors: etanercept, certolizumab, golimumab, adalimumab.

Other biologic DMARDsAbatacept (biologic), other targeted synthetic DMARDs such as tofacitinib and upadacitinib.

Clinical noteUse of Olumiant in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants (e.g., azathioprine, cyclosporine) is not recommended.

Context of termUsed in step-therapy and combination-therapy exclusion language for rheumatoid arthritis and severe alopecia areata criteria.

Background

Olumiant (baricitinib) is a Janus Kinase (JAK) inhibitor indicated for adults with moderately to severely active rheumatoid arthritis after inadequate response to prior therapies and for adults with severe alopecia areata. The policy reiterates that use in combination with other JAK inhibitors, biologic DMARDs, or potent immunosuppressants (for example, azathioprine or cyclosporine) is not recommended.

Site of Care / Pharmacy

Note

Plan or program supply limits may apply

Supply limits for Olumiant may apply according to the member’s plan or program; check applicable plan-level limits when submitting pharmacy requests.

Revision History

2025-06-01policy_effectiveLatest

Policy effective date updated to 2025-06-01 reflecting addition of alopecia areata coverage criteria and prescriber requirements for AA.

2023-11non_material_update

Removed criteria regarding duration of current AA episode (administrative/content cleanup); no change to coverage criteria specified.

2023-09examples_updated