ModifiedPremera BluecrossPolicy N/A

Pharmacologic Treatment of Alopecia

Defines medical necessity criteria for oral therapies Leqselvi (deuruxolitinib), Litfulo (ritlecitinib), and Olumiant (baricitinib) for severe alopecia areata when covered by the member's benefit plan; applies to prescribers and prior authorization reviewers.

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Alopecia

Policy CodePolicy N/A

Change TypeRevised (2026) with material updates

Effective DateJun 1, 2026

Next Review DateMay 25, 2026

Key ActionSubmit prior authorization with documentation of severe alopecia areata (≥50% scalp hair loss, episode ≥6 months) and prior inadequate response to topical therapy.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for Leqselvi (deuruxolitinib) for the treatment of severe alopecia areata.

Clarified that non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months.

Updated criteria for Olumiant (baricitinib) adding the quantity is limited to 30 tablets per 30 days and removed reference to nonformulary exception reviews.

Non-formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months.

Medications listed in this policy are subject to the product's FDA dosage and administration prescribing information.

Updated criteria for Olumiant (baricitinib) adding the quantity is limited to 30 tablets per 30 days.

Removed reference to nonformulary exception reviews.

>=50%minimum scalp hair loss required for 'severe alopecia areata' coverage

6 months

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

inv-01: Leqselvi (deuruxolitinib) Initial Therapy

Leqselvi (deuruxolitinib) is covered when ALL of the following are met:

Leqselvi (deuruxolitinib) coverage criteria: Individual is aged 18 years or older

Leqselvi (deuruxolitinib) coverage criteria: Has a diagnosis of severe alopecia areata

Leqselvi (deuruxolitinib) coverage criteria: Has had greater than or equal to 50% of scalp hair loss>=50% scalp hair loss

Measured by SALT or equivalent clinical assessment

Leqselvi (deuruxolitinib) coverage criteria: Has had an inadequate response or relapse after at least one of: topical immunotherapy (e.g., diphenylcyclopropenone (DPCP)) OR topical corticosteroid (e.g., betamethasone dipropionate)

Leqselvi (deuruxolitinib) coverage criteria: Has current alopecia areata episodes lasting at least 6 months without spontaneous re-growth>=6 months

Leqselvi (deuruxolitinib) coverage criteria: Is NOT using Leqselvi in combination with any of the following: JAK inhibitors, biologic immunomodulators, cyclosporine, or potent immunosuppressants (e.g., methotrexate, azathioprine)

Concurrent therapy exclusion

Leqselvi (deuruxolitinib) coverage criteria: Maximum prescribed dose is 16 mg daily<=16 mg daily

Refer to FDA prescribing information for dosing guidance

Leqselvi (deuruxolitinib) coverage criteria: Medication is being prescribed by or in consultation with a dermatologist

Refer to benefit plan for coverage availability

inv-02: Litfulo (ritlecitinib) Initial Therapy

Litfulo (ritlecitinib) is covered when ALL of the following are met:

Litfulo (ritlecitinib) coverage criteria: Individual is aged 12 years or olderage >=12 years

Applies to adolescents and adults

Litfulo (ritlecitinib) coverage criteria: Has a diagnosis of severe alopecia areata

Litfulo (ritlecitinib) coverage criteria: Has had greater than or equal to 50% of scalp hair loss>=50% scalp hair loss

Measured by SALT or equivalent clinical assessment

Litfulo (ritlecitinib) coverage criteria:

inv-03: Olumiant (baricitinib) Initial Therapy

Olumiant (baricitinib) is covered when ALL of the following are met:

Olumiant (baricitinib) coverage criteria: Individual is aged 18 years or olderage >=18 years

Olumiant (baricitinib) coverage criteria: Has a diagnosis of severe alopecia areata

Olumiant (baricitinib) coverage criteria: Has had greater than or equal to 50% of scalp hair loss>=50% scalp hair loss

Measured by SALT or equivalent clinical assessment

Olumiant (baricitinib) coverage criteria:

inv-04: Approval Duration and Reauthorization

Length of approval and reauthorization:

Approval duration and reauthorization: Initial authorization up to 12 months<=12 months

Approvals may be up to 12 months

Approval duration and reauthorization: Re-authorization up to 12 months when chart notes document >=50% hair regrowth>=50% hair regrowth

Clinical benefit/response required at re-authorization

Benefit-plan coverage varies. Many benefit plans exclude drugs for alopecia; coverage for Leqselvi, Litfulo, and Olumiant depends on the member’s specific benefit document. Refer to the applicable benefit plan to determine benefit availability and any terms, conditions, or limitations of coverage, and contact the number on the member’s ID card for benefit questions.

Nonformulary exception language removed in 2026 update. The prior reference to nonformulary exception reviews was removed from this policy as part of the 2026 update; see policy history for details of the change.

Other uses are investigational. All uses of the drugs listed in this policy that are not specifically outlined here (and in policy 5.01.550) are considered investigational and are not covered under the policy’s medical necessity criteria.

Coding and Diagnostic Thresholds

Coding related informationmixed

No codes listed

Minimum scalp hair loss

Threshold>= 50% scalp hair loss (measured by SALT)

Applies toLeqselvi, Litfulo, Olumiant coverage criteria

ContextDefined as part of 'severe alopecia areata' for prior authorization determinations

Minimum episode duration without spontaneous regrowth

Threshold>= 6 months without spontaneous regrowth

Applies toLeqselvi, Litfulo, Olumiant coverage criteria

Use at authorization

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial and re-authorization approvals may be granted for up to 12 months when criteria are met and documentation supports medical necessity.

Prior authorization required with documentation meeting drug-specific criteria
Approval duration: up to 12 months for initial and re-authorization when clinical benefit is demonstrated

Denial Risk

Quantity Limits and Enforcement

Olumiant (baricitinib) is subject to a quantity limit of 30 tablets per 30 days. Prior authorization requests exceeding this quantity may be denied or not authorized.

Olumiant limited to 30 tablets per 30 days
Exceeding the quantity limit may trigger denial or non-authorization

Drug-Specific Initial Therapy Criteria

inv-22: Drug-specific initial therapy

Initial coverage requirements per drug:

Leqselvi initial: Individual is aged 18 years or older AND diagnosis of severe alopecia areata AND >=50% scalp hair loss AND inadequate response or relapse after at least one of topical immunotherapy or topical corticosteroid AND current episode >=6 months without spontaneous re-growth AND not used in combination with JAK inhibitors, biologic immunomodulators, cyclosporine, or potent immunosuppressants AND maximum prescribed dose 16 mg daily AND prescribed by or in consultation with a dermatologistsee individual drug criteria

Leqselvi added to policy in 2024 update

Litfulo initial: Individual is aged 12 years or older AND diagnosis of severe alopecia areata AND >=50% scalp hair loss AND inadequate response or relapse after at least one of topical immunotherapy or topical corticosteroid AND current episode >=6 months without spontaneous re-growth AND not used in combination with JAK inhibitors, biologic immunomodulators, cyclosporine, or potent immunosuppressants AND maximum prescribed dose 50 mg once daily AND prescribed by or in consultation with a dermatologistsee individual drug criteria

Continuation / Re-authorization Criteria

inv-23: Continuation/Re-authorization

Re-authorization criteria:

Re-authorization for Leqselvi, Litfulo, Olumiant: Chart notes document clinical benefit/response at time of re-authorization showing greater than or equal to 50% hair regrowth>=50% hair regrowth

Re-authorization may be up to 12 months

Step Therapy Requirements

Step	Requirement	Failure definition
1	Prior topical therapy trial required before coverage	Inadequate response or relapse after at least one of: topical immunotherapy (e.g., diphenylcyclopropenone [DPCP]) OR topical corticosteroid (e.g., betamethasone dipropionate)

Quantity Limits

Olumiant (baricitinib) — Quantity limit

Quantity limit30 tablets per 30 days

DrugOlumiant (baricitinib)

EnforcementExceeding this quantity may trigger denial or not be authorized

Olumiant (baricitinib) — Quantity limit (duplicate)

Quantity limit (duplicate)30 tablets per 30 days

DrugOlumiant (baricitinib)

NoteQuantity limit was added/confirmed in 2026 policy update

Definitions

Severe alopecia areata — Policy definition

DefinitionSevere alopecia areata defined as >=50% scalp hair loss (SALT) and current episode lasting >=6 months without spontaneous regrowth

MeasurementScalp hair loss assessed by percent affected (SALT) per policy criteria

Use in policyRequired threshold for coverage determinations for Leqselvi, Litfulo, and Olumiant

Prescribing Information — Policy references

DefinitionPrescribing Information = Official FDA-approved drug labeling documents cited in the policy references for each medication

References CitedLeqselvi (deuruxolitinib) PI; Litfulo (ritlecitinib) PI; Olumiant (baricitinib) PI

Background

Alopecia areata is a chronic, immune-mediated disorder characterized by sudden, patchy hair loss on the scalp and other body areas. Most patients eventually experience hair regrowth, but regrowth may be slow and the condition can have significant psychosocial impact. FDA-approved oral JAK inhibitors referenced in this policy for severe alopecia areata include Leqselvi (deuruxolitinib), Litfulo (ritlecitinib), and Olumiant (baricitinib).

For coverage determinations, note that drugs for alopecia may be excluded by the member’s benefit plan; always confirm benefit availability with the applicable benefit document.