CurrentUnitedHealthcarePolicy 2025 P 1382-4

Pa Notification Cibinqo

Defines UnitedHealthcare prior authorization and reauthorization clinical criteria and rules for Cibinqo (abrocitinib) tablets, including eligibility, required prior treatment failure/intolerance, combination-agent prohibitions, and authorization durations.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Cibinqo

Policy CodePolicy 2025 P 1382-4

Change TypeAnnual reviewsprogram additions/updates

Effective DateMay 16, 2025

Next Review Date

Key ActionPrior authorization/notification is required for Cibinqo; initial approvals are for 12 months and reauthorizations require documentation of positive clinical response and absence of prohibited concomitant therapies.

SourceLink

POLICY UPDATE CHANGES

New program created 3/2022.

Annual review 3/2023.

Annual review 3/2024 updated background and expanded indication to patients 12 years and older; added state mandate footnote.

Annual review 3/2024 (later) removed age requirement from criteria.

Annual review 4/2025 with no changes to coverage criteria.

12Months per approval

1Required prior systemic therapy

3Prohibited concomitant therapy classes

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Coverage Summary

Cibinqo (abrocitinib) is a Janus kinase (JAK) inhibitor indicated for adults and pediatric patients 12 years of age and older with refractory, moderate-to-severe atopic dermatitis not adequately controlled with other systemic drug products. It should not be used in combination with other JAK inhibitors, biologic immunomodulators, or potent immunosuppressants.

Initial Authorization

Cibinqo will be approved based on all of the following criteria:

ALL of the following

Diagnosis of moderate-to-severe chronic atopic dermatitis
History of failure, contraindication, or intolerance to at least one systemic drug product for the treatment of atopic dermatitis
Not receiving concomitant therapies
- Patient is not receiving Cibinqo in combination with a biologic immunomodulator (e.g., Adbry (tralokinumab-ldrm), Dupixent (dupilumab), Ebglyss (lebrikizumab-lbkz), Nemluvio (nemolizumab-ilto))
- Patient is not receiving Cibinqo in combination with another Janus kinase inhibitor (e.g., Olumiant (baricitinib), Opzelura (topical ruxolitinib), Rinvoq (upadacitinib), Xeljanz/XR (tofacitinib))
- Patient is not receiving Cibinqo in combination with a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)

Authorization Duration (Initial)

When initial criteria met:

Authorization will be issued for 12 months

Continuation / Reauthorization Criteria

Reauthorization

Cibinqo will be approved for reauthorization based on both of the following criteria:

Documentation of positive clinical response to Cibinqo therapy

Not receiving concomitant therapies

Patient is not receiving Cibinqo in combination with a biologic immunomodulator (e.g., Adbry (tralokinumab-ldrm), Dupixent (dupilumab), Ebglyss (lebrikizumab-lbkz), Nemluvio (nemolizumab-ilto))
Patient is not receiving Cibinqo in combination with another Janus kinase inhibitor (e.g., Olumiant (baricitinib), Opzelura (topical ruxolitinib), Rinvoq (upadacitinib), Xeljanz/XR (tofacitinib))
Patient is not receiving Cibinqo in combination with a potent immunosuppressant (e.g., azathioprine, cyclosporine, mycophenolate mofetil)

Prohibited Concomitant Therapies / Exclusions

The policy prohibits concomitant use of Cibinqo with: (a) biologic immunomodulators (examples: Adbry (tralokinumab-ldrm), Dupixent (dupilumab), Ebglyss (lebrikizumab-lbkz), Nemluvio (nemolizumab-ilto)); (b) other Janus kinase inhibitors (examples: Olumiant (baricitinib), Opzelura (topical ruxolitinib), Rinvoq (upadacitinib), Xeljanz/XR (tofacitinib)); and (c) potent immunosuppressants (examples: azathioprine, cyclosporine, mycophenolate mofetil).

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Prior authorization/notification is required for Cibinqo; initial approvals are for 12 months and reauthorizations require documentation of positive clinical response and absence of prohibited concomitant therapies.

Documentation Required

Document prior systemic therapy failure/intolerance

Provider must document history of failure, contraindication, or intolerance to at least one systemic drug product for atopic dermatitis for initial authorization.

Documentation Required

Document positive clinical response for reauthorization

Provider must document positive clinical response to Cibinqo therapy for reauthorization.

Applicable Codes

NDC / HCPCS / CPT codesmixed

No codes listed

ICD-10 (diagnosis guidance)ICD-10

No codes listed

Clinical Evidence & Definitions

P&T approval dates: 3/2022, 3/2023, 3/2024, 4/2025.

Key reference: Cibinqo [package insert], Pfizer Inc.; December 2023.

Positive clinical response: clinical improvement documented by the provider while on Cibinqo (no specific metric defined in the policy).

Systemic drug product: non-topical systemic therapies for atopic dermatitis, including biologics and oral immunomodulators.

Background

Background: Cibinqo is a Janus kinase (JAK) inhibitor indicated for the treatment of adults and pediatric patients 12 years of age and older with refractory, moderate-to-severe atopic dermatitis whose disease is not adequately controlled with other systemic drug products, including biologics, or when use of those therapies is inadvisable. Limitation of Use: Cibinqo is not recommended in combination with other JAK inhibitors, biologic immunomodulators, or with other immunosuppressants.

Revision History

3/2022added

New program created 3/2022. Initial creation of prior authorization/notification program for Cibinqo.

3/2023revised

Annual review 3/2023. P&T approval and program maintenance.

3/2024revised

Annual review 3/2024 updated background and expanded indication to patients 12 years and older; added state mandate footnote. Updated background and criteria to reflect expanded indication for patients 12 years of age and older; updated reference.