ModifiedPremera BluecrossPolicy N/A

Pharmacologic treatment of alopecia areata (Leqselvi, Litfulo, Olumiant)

Defines medical necessity criteria, documentation, approval durations, and prescribing constraints for Leqselvi (deuruxolitinib), Litfulo (ritlecitinib), and Olumiant (baricitinib) when used to treat severe alopecia areata for members whose benefit plans cover these drugs.

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic treatment of alopecia areata (Leqselvi, Litfulo, Olumiant)

Policy CodePolicy N/A

Change TypeAdded Leqselvi criteriarevised Olumiant quantity limit

Effective DateJun. 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis (≥50% scalp hair loss), duration ≥6 months, prior topical therapy failure, and prescriber dermatologist involvement.

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.

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

Reference to nonformulary exception reviews was removed.

>=50%SALT threshold

>=6 moEpisode duration

12 moApproval length

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16 mg/dayLeqselvi max dose

Coverage Criteria

Many benefit plans exclude coverage for drugs used to treat alopecia. Providers should verify benefit availability and any plan-specific terms, conditions, or limitations by referring to the member's applicable benefit plan document or contacting customer service using the telephone number on the member's ID card.

This medical policy does not apply to Medicare Advantage.

All other uses of the listed drugs (Leqselvi, Litfulo, Olumiant) for conditions not described in this policy and policy 5.01.550 are considered investigational.

Key Clinical Thresholds

Minimum scalp hair loss (SALT) — Threshold

Minimum scalp hair loss (SALT)≥50% scalp hair loss

Measurement toolSeverity of Alopecia Tool (SALT)

Applies toEligibility requirement for Leqselvi, Litfulo, and Olumiant

Policy contextDefines ‘severe’ alopecia areata when ≥50% scalp hair loss is present

Duration of current episode — Threshold

Required duration>= 6 months without spontaneous regrowth

Policy impactRequired for initial medical necessity for Leqselvi, Litfulo, and Olumiant

Measured atDuration of current alopecia areata episode

DocumentationChart or office notes must document episode length to meet criteria

Provider Requirements and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for Leqselvi (deuruxolitinib), Litfulo (ritlecitinib), and Olumiant (baricitinib). Requests must document age, diagnosis of severe alopecia areata with ≥50% scalp hair loss, current episode duration ≥6 months, prior inadequate response or relapse after at least one topical therapy (topical immunotherapy e.g., DPCP, or topical corticosteroid), and that the medication is prescribed by or in consultation with a dermatologist. Initial approvals may be for up to 12 months and prescribing must follow the product's FDA dosage and administration information.

Initial authorization: up to 12 months
Re-authorization: chart notes documenting ≥50% hair regrowth for continued approval
Prescribing must follow FDA dosage and administration information

Prior Authorization

Prior Authorization and Quantity Limit

Quantity limit applies to Olumiant (baricitinib): the quantity is limited to 30 tablets per 30 days. Requests exceeding this quantity may be denied.

Background

Alopecia areata is a chronic, immune-mediated disorder characterized by patchy hair loss. Many patients eventually experience hair regrowth, but regrowth can take a long time and disease course varies; treatment decisions should consider the potential psychosocial impact and the expected timeline for spontaneous regrowth.

Definitions and Measurement Tools

Severe alopecia areata — Definition

DefinitionAlopecia areata with ≥50% scalp hair loss as measured by the Severity of Alopecia Tool (SALT)

Use in policyServes as the diagnostic threshold for ‘severe’ alopecia areata referenced across approvals

Applies toLeqselvi, Litfulo, and Olumiant coverage criteria

SALT response — Trial endpoints and thresholds

SALT response exampleSALT ≤20 corresponds to approximately ≥80% scalp hair coverage (trial primary endpoint for ~80% coverage)

Other thresholdsSALT ≤10 corresponds to ≥90% scalp hair coverage used in some trial endpoints

Revision History

2026-05-25annual_reviewLatest

Updated criteria for Olumiant (baricitinib) to add a quantity limit of 30 tablets per 30 days and removed reference to non‑formulary exception reviews.

2025-03-24annual_review

Clarified that non‑formulary exception review authorizations for all drugs listed in this policy may be approved up to 12 months and affirmed that medications are subject to FDA dosing and administration information.

2024-11-12

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic treatment of alopecia areata (Leqselvi, Litfulo, Olumiant)

Policy CodePolicy N/A

Change TypeAdded Leqselvi criteriarevised Olumiant quantity limit

Effective DateJun. 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis (≥50% scalp hair loss), duration ≥6 months, prior topical therapy failure, and prescriber dermatologist involvement.

SourceLink

On This Page

Olumiant (baricitinib): 30 tablets per 30 days

Requests exceeding this limit may be denied

Step Therapy

Step Therapy — Prior Topical Therapy Required

Step therapy requirement: members must have had an inadequate response or relapse after at least one prior topical therapy for alopecia areata (topical immunotherapy such as diphenylcyclopropenone (DPCP) or a topical corticosteroid such as betamethasone dipropionate) before advanced therapies will be approved.

Required prior topical therapy: topical immunotherapy (e.g., DPCP) OR topical corticosteroid (e.g., betamethasone dipropionate)

Denial Risk

Prohibited Drug Combinations

The requested medication must NOT be used in combination with other JAK inhibitors, biologic immunomodulators, cyclosporine, or potent immunosuppressants (e.g., methotrexate, azathioprine). Use in combination with these agents is a basis for denial.

Prohibited combinations: JAK inhibitors (e.g., tofacitinib), biologic immunomodulators, cyclosporine, potent immunosuppressants (e.g., methotrexate, azathioprine)

Documentation Required

Required Clinical Documentation

Documentation must include office visit notes showing the diagnosis of alopecia areata, prior treatments, and duration of current episode. For re-authorization, submit chart notes documenting clinical benefit defined as ≥50% hair regrowth.

Office visit notes with diagnosis and prior treatments are required
Re-authorization requires documentation of ≥50% hair regrowth

Major drug trials used SALT thresholds (≤20 or ≤10) as primary/secondary endpoints

Prescribing Information — Policy statement

Prescribing Information adherenceMedications listed are subject to the product's FDA dosage and administration prescribing information

Referenced sourcesPolicy cites each drug’s FDA Prescribing Information (Leqselvi, Litfulo, Olumiant)

Policy notePrescribers must follow FDA-approved dosing and administration for each product

Added coverage criteria for Leqselvi (deuruxolitinib) for the treatment of severe alopecia areata and added a summary of evidence for Leqselvi.

2023-08-08new_policy

New policy approved adding coverage criteria for Olumiant (baricitinib) and Litfulo (ritlecitinib) for the treatment of severe alopecia areata.