abrocitinib — Blue Cross Blue Shield of Texas

Initial criteria

• The requested agent is eligible for continuation of therapy AND the prescriber states the patient has been treated with the requested agent (not samples) within the past 90 days AND is at risk if therapy is changed OR new start criteria must be met
• For new start: patient has diagnosis of moderate-to-severe atopic dermatitis AND meets ONE of the following disease severity criteria: (i) ≥10% body surface area involvement OR (ii) involvement of difficult-to-treat sites (hands, feet, face, neck, scalp, genitals/groin, skin folds) OR (iii) EASI score ≥16 OR (iv) IGA score ≥3
• AND patient meets ONE of the following treatment history options: (A) failed/inadequate response after ≥4-week duration OR intolerance OR contraindication to ≥1 medium-potency topical corticosteroid used for AD AND failed/inadequate response after ≥6-week duration OR intolerance OR contraindication to ≥1 topical calcineurin inhibitor (e.g., Elidel, Protopic); OR (B) patient’s medication history shows use of another biologic immunomodulator agent FDA labeled or compendia-supported for AD
• If patient has another FDA labeled indication: patient’s age is within labeling OR supported by compendia
• If patient has moderate-to-severe AD: patient is currently treated with topical emollients and good skin care AND will continue these practices in combination with Cibinqo
• Patient has been tested for latent tuberculosis and, if positive, has begun therapy for latent TB
• Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted one
• Requested agent will NOT be used with other immunomodulatory agents (TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR combination use is justified with supportive evidence AND PI allows use
• Patient does NOT have any FDA labeled contraindications to abrocitinib
• Compendia allowed: AHFS, DrugDex level 1,2a,2b, NCCN 1,2a,2b

Reauthorization criteria

• Patient was previously approved through plan’s prior authorization process
• Patient has had clinical benefit with the requested agent
• If patient has AD, continues standard maintenance therapies with topical emollients and good skin care with Cibinqo
• Prescriber is or has consulted a specialist (dermatologist, allergist, immunologist)
• Agent not used with other immunomodulatory drugs unless supported and allowed
• No FDA labeled contraindications to abrocitinib

Approval duration

12 months