CurrentMass General Brigham Health PlanPolicy N/A

Litfulo (ritlecitinib)

Prior authorization policy for Litfulo (ritlecitinib) under the pharmacy benefit for Commercial/Exchange members (specialty drug, filled at contracted specialty pharmacy). Defines initial and continuation criteria, age and disease severity thresholds, quantity limits, approval durations, and documentation requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicyLitfulo (ritlecitinib)

Policy CodePolicy N/A

Change TypeClarified; Revised

Effective DateMay 1, 2026

Next Review Date

Key ActionPrior authorization required under the pharmacy benefit for Litfulo; specialty designation requires fill at a contracted specialty pharmacy.

SourceLink

POLICY UPDATE CHANGES

09/10/2025 update: reauthorization criteria updated to require documentation of improvement and initial approval length updated to 36 weeks (effective 12/01/2025).

Administrative update changing reauthorization verbiage to require 'submission of medical records (e.g., chart notes...)' and updated language for members who are new to the plan.

12+Minimum Age (years)

SALT ≥50Severity Threshold

36wInitial Approval Length

12m

Reauthorization Length

Coverage Summary

Prior authorization is required under the pharmacy benefit for Litfulo (ritlecitinib) for Commercial/Exchange members. The drug is designated as a specialty medication and must be filled at a contracted specialty pharmacy. Coverage is covered with criteria that include age, diagnosis, and severity thresholds and specified documentation and approval durations.

Key thresholds and approval lengths

Minimum Age12 years or older

Severity ThresholdSevere alopecia areata with SALT ≥50 (more than 50% scalp hair loss)

SALT score / Scalp hair loss> 50% scalp hair loss (SALT score of 50 or higher)

Initial Approval Length36 weeks

Reauthorization Length12 months

Initial Therapy Criteria

Initial Authorization / Medical Necessity

Authorization may be granted for members meeting ALL of the following criteria:

Age: Member is at least 12 years of age or older≥ 12 years
Based on indication for adults and adolescents 12 years and older.
Diagnosis: Member has a diagnosis of severe alopecia areata
Severity: Member has more than 50% scalp hair loss (Severity of Alopecia Tool [SALT] score of 50 or higher)SALT ≥ 50
Policy requires SALT score of 50 or higher for coverage.

Continuation Therapy Criteria (Reauthorization)

Continuation of Therapy / Reauthorization

Requests for reauthorization will be approved when ALL of the following criteria are met:

Documentation of improvement: Submission of medical records (e.g., chart notes) supporting improvement in signs and symptoms of alopecia areata from baseline (e.g., increased hair on scalp, eyebrows, eyelashes)
Examples include increased hair on scalp, eyebrows, eyelashes.

Approval durations (quick reference)

Initial approvals36 weeks

Reauthorizations12 months

Provider Actions & Billing Rules

Prior Authorization

Prior Authorization Requirement

Prior authorization required under the pharmacy benefit for Litfulo; specialty designation requires fill at a contracted specialty pharmacy.

Documentation Required

New-to-Plan Documentation

If member's coverage effective date is ≤ 90 days, submit medical records documenting current receipt of the requested drug. Do not include samples or manufacturer patient assistance program supply.

Applicable Codes

Benefit / Programmixed

No codes listed

Clinical Evidence

Evidence sources include the product Prescribing Information: Litfulo (ritlecitinib) [prescribing information], Pfizer Inc.; June 2023, and the pivotal randomized, double-blind, multicentre phase 2b-3 trial published in The Lancet (2023;401:1518-1529) demonstrating efficacy and safety.

Clinical evidence (sources)

Prescribing informationLitfulo (ritlecitinib) — Pfizer; June 2023

Key trialRandomised phase 2b-3 trial — Lancet 2023

Background & Definitions

Litfulo (ritlecitinib) is indicated for treatment of severe alopecia areata in adults and adolescents 12 years and older. It is not recommended to be used in combination with other JAK inhibitors, biologic immunomodulators, cyclosporine, or other potent immunosuppressants. The medication is designated as a specialty drug and must be dispensed through a contracted specialty pharmacy.

Term	Definition
SALT score	Severity of Alopecia Tool score; used to quantify scalp hair loss (policy requires SALT score of 50 or higher).
New to the plan	Member with coverage effective date less than or equal to 90 days; requires submission of medical records documenting that the member is currently receiving treatment with the requested drug (excluding samples or manufacturer's patient assistance program supply).

Revision History

2025-09-10revised

09/10/2025 clinical/coverage update: reauthorization criteria updated to require documentation of improvement in signs and symptoms of alopecia areata; initial approval length updated to 36 weeks (effective 12/01/2025).

2026-05-01clarifiedLatest

05/01/2026 administrative update: wording in reauthorization criteria changed to require 'submission of medical records (e.g., chart notes...)' and language updated for members who are new to the plan (coverage effective date ≤ 90 days); specialty dispensing and prior authorization details reiterated.

Policy Summary

PayerMass General Brigham Health Plan

PolicyLitfulo (ritlecitinib)

Policy CodePolicy N/A

Change TypeClarified; Revised

Effective DateMay 1, 2026

Next Review Date

Key ActionPrior authorization required under the pharmacy benefit for Litfulo; specialty designation requires fill at a contracted specialty pharmacy.

SourceLink

On This Page

Exclusions: Other forms of alopecia have been ruled out (e.g., androgenetic alopecia, trichotillomania, telogen effluvium, chemotherapy-induced hair loss, tinea capitis)

New-to-Plan Documentation: If member is new to the plan (coverage effective date ≤ 90 days), submission of medical records documenting that the member is currently receiving treatment with the requested drug (excluding samples or manufacturer patient assistance program supply)Coverage effective date ≤ 90 days

Documentation must exclude samples and manufacturer patient assistance program supply.

Designated specialty drug requiring specialty pharmacy dispensing; not recommended for use in combination with other JAK inhibitors, biologic immunomodulators, cyclosporine, or other potent immunosuppressants.

Documentation Required

Reauthorization Documentation

Submit medical records (e.g., chart notes) demonstrating improvement in signs and symptoms of alopecia areata from baseline (for example, increased hair on scalp, eyebrows, or eyelashes) to support reauthorization.

Billing Rule

Quantity Limit

Litfulo tablet — 1 tablet per day.

Prior Authorization

Approval Durations

Initial approvals granted for 36 weeks; reauthorizations granted for 12 months.