CurrentMass General Brigham Health PlanPolicy N/A

Cibinqo (abrocitinib) prior authorization and coverage

This document defines prior authorization, step therapy, quantity limits, and continuation criteria for Cibinqo (abrocitinib) for members of Mass General Brigham Health Plan (MassHealth/Commercial) and specifies specialty pharmacy and benefit routing.

Policy Summary

PayerMass General Brigham Health Plan

PolicyCibinqo (abrocitinib) prior authorization and coverage

Policy CodePolicy N/A

Change TypeMaterial updates to eligibility, step therapy, and authorization durations

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document trial/failure of required topical and systemic therapies and, for reauthorization, submit documentation of clinical improvement.

SourceLink

POLICY UPDATE CHANGES

Ebglyss was added as a systemic step-through option.

Approval length updated to 6 months initial and 12 months for reauthorization.

Approvable age lowered from 18 to 12 years to align with updated labeling and diagnosis criteria specified as 'refractory' disease.

Topical step therapy requirements updated to include Eucrisa and specify minimum trial lengths (30 days for most, 14 days for topical corticosteroids).

Reauthorization criteria updated to require documentation of clinical improvement (e.g., clear or almost clear skin or improvement in signs/symptoms).

≥12Minimum age for coverage

BSA ≥10%Disease extent threshold

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Coverage Criteria

Initial Therapy

Authorization may be granted when ALL of the following are met:

Initial Approval: Member meets all criteria listed

Age: Member is 12 years of age or older≥ 12 years

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Diagnosis: Member has a diagnosis of refractory, moderate-to-severe atopic dermatitis

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Extent: Affected body surface area >= 10% OR involvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)BSA >=10% or crucial area involvement

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Topical therapy trial: Trial, intolerance, or contraindication to at least ONE of: medium or higher potency topical corticosteroid (minimum 14-day trial for topical corticosteroids), pimecrolimus cream, tacrolimus ointment, or Eucrisa (minimum 30-day trial for other topicals)30 days (14 days for topical corticosteroids)

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Systemic biologic trial: Trial, intolerance, or contraindication to at least ONE of the following systemic biologics: Adbry, Dupixent, or Ebglyss

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Continuation of Therapy

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

Reauthorization: Documentation supports clinical improvement in the member's condition

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Clinical improvement examples: Low disease activity (e.g., clear or almost clear skin) OR improvement in signs/symptoms (e.g., redness, itching, oozing/crusting)

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Approval length and dispensing: Reauthorizations will be granted for 12 months when criteria are met; quantity limit 1 tablet per day across strengths12 months; 1 tablet/day

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Members who are new to the plan within the past 90 days may be eligible for coverage of Cibinqo (abrocitinib) if they are currently receiving the requested medication. Coverage under this clause excludes products obtained as samples or through manufacturer patient assistance programs.

Use of Cibinqo is not supported for patients who do not meet the specified age, diagnosis, extent, or required step-therapy/trial-failure criteria. Specifically, authorization requires the member to be ≥12 years old, have a diagnosis of refractory, moderate-to-severe atopic dermatitis, and disease extent meeting BSA ≥10% or involvement of crucial body areas. Prior to approval the member must have trialed and had failure, intolerance, or contraindication to at least one qualifying topical option (medium-or-higher potency topical corticosteroid, pimecrolimus cream, tacrolimus ointment, or Eucrisa — minimum trial length 30 days, 14 days for topical corticosteroids) and to at least one systemic biologic (Adbry, Dupixent, or Ebglyss).

Coding and Clinical Thresholds

Codingmixed

N/A	No specific CPT/HCPCS/ICD-10 codes listed in document

Body surface area — >= 10% or involvement of crucial body areas

Disease extent thresholdAffected body surface area >= 10% OR involvement of crucial body areas (hands, feet; face, neck, scalp, genitals/groin, intertriginous areas)

Threshold typeBody surface area (BSA)

Numeric criterion>= 10% BSA

Anatomic criterionInvolvement of crucial body areas as alternative to BSA threshold

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

This medication is designated specialty and must be dispensed through a contracted specialty pharmacy. Prior authorization is required for initial and continuation therapy. Initial authorizations are granted for 6 months; reauthorizations are granted for 12 months.

Specialty pharmacy routing required — contact contracted specialty pharmacy for Medical and Specialty Medications: Phone: 877-519-1908 | Fax: 855-540-3693
Initial prior authorization duration: 6 months
Reauthorization duration: 12 months

Step Therapy

Required Topical and Systemic Therapy Trials

Before approval, members must have trialed and had failure, intolerance, or contraindication to specified topical and systemic therapies. For topicals, a minimum 30‑day supply is required (14 days for topical corticosteroids).

Topical therapy trial requirement: trial and failure, intolerance, or contraindication to at least ONE of: Medium or higher potency topical corticosteroid, Pimecrolimus cream, Tacrolimus ointment, or Eucrisa

Background

Abrocitinib (Cibinqo) is an oral Janus kinase (JAK) inhibitor indicated for treatment of patients 12 years of age and older with refractory, moderate-to-severe atopic dermatitis not adequately controlled with other systemic therapies or when such therapies are inadvisable.

Definitions

Refractory, moderate-to-severe atopic dermatitis — definition and clinical context

DefinitionAtopic dermatitis of moderate-to-severe intensity that is refractory—i.e., not adequately controlled with other systemic drug products, including biologics, or when those therapies are inadvisable.

Age contextIndicated for patients 12 years of age and older

Clinical qualifiersDisease described as moderate-to-severe and refractory to other systemic therapies

Extent considerationsMay include extent criteria such as BSA >=10% or involvement of crucial body areas