abrocitinib — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following: (A) Continuation of therapy: prescriber states patient has been treated with the requested agent within past 90 days and is at risk if therapy is changed OR (B) New start: ALL of the following criteria apply
• For new starts: ONE of the following: (A) Diagnosis of moderate-to-severe atopic dermatitis (AD) AND ALL of the following conditions are met OR (B) Another FDA labeled indication for the requested agent and route of administration
• For atopic dermatitis: ONE of the following disease severity criteria: patient has at least 10% body surface area involvement OR involvement of difficult-to-treat sites (hands, feet, face, neck, scalp, genitals/groin, skin folds) OR EASI score ≥16 OR IGA score ≥3
• For atopic dermatitis: ONE of the following treatment history requirements is met: (A) inadequate response after ≥4 weeks to one medium-potency topical corticosteroid OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL medium/high/super-potency topical corticosteroids AND ONE of the following for topical calcineurin inhibitors: inadequate response after ≥6 weeks to one topical calcineurin inhibitor (e.g., Elidel, Protopic) OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL topical calcineurin inhibitors OR the patient's medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for AD
• Patient’s age is within FDA labeling for the requested indication OR support exists for use at that age
• For atopic dermatitis, BOTH of the following: patient is currently treated with topical emollients and practicing good skin care AND will continue these in combination with the requested agent
• Patient has been tested for latent tuberculosis (TB) and if positive has begun therapy for latent TB
• Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted such a specialist
• ONE of the following: (A) The patient will NOT use requested agent with another immunomodulator (TNF inhibitors, JAK inhibitors, IL‑4 inhibitors) OR (B) Combination allowed if agent labeling does not limit such use AND supporting evidence is submitted
• Patient does NOT have any FDA labeled contraindications to Cibinqo
• If member resides in Ohio and plan is Fully Insured or HIM Shop, approval may be given if patient has no contraindications AND (1) holds another FDA labeled indication OR (2) indication supported in compendia OR (3) prescriber submitted two peer‑reviewed articles supporting proposed use

Reauthorization criteria

• Patient previously approved through plan’s Prior Authorization process
• Patient has had clinical benefit with requested agent
• If diagnosis is moderate‑to‑severe atopic dermatitis, will continue standard maintenance therapies (e.g., topical emollients, good skin care) in combination with Cibinqo
• Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted a specialist
• ONE of the following: (A) Patient will NOT use requested agent with another immunomodulator (TNF/JAK/IL‑4 inhibitor) OR (B) Combination allowed if agent labeling does not limit such use and supporting evidence is provided
• Patient does NOT have any FDA labeled contraindications to Cibinqo

Approval duration

6 months (initial); 12 months (renewal)