Leqselvi — CareFirst (Caremark)

Severe alopecia areata

Preferred products

Age ≥ 18 years (adult member)
Prescribed by or in consultation with a dermatologist
Member has at least 50% scalp hair loss (e.g., Severity of Alopecia Tool [SALT] score ≥ 50)
Other forms of alopecia have been ruled out (e.g., androgenetic alopecia, trichotillomania, telogen effluvium, chemotherapy-induced hair loss, tinea capitis)
Member has had a documented negative tuberculosis (TB) test (which can include a tuberculosis skin test [TST] or an interferon-release assay [IGRA]) within 12 months of initiating therapy for persons naïve to biologic drugs or targeted synthetic drugs associated with increased TB risk
If TB screening test is positive, further testing confirms no active disease (e.g., chest x-ray)
Do not administer medication in members with active TB infection; if latent disease, TB treatment must start before initiation
Medication is not used concomitantly with any other biologic drug, targeted synthetic drug, or potent immunosuppressant such as azathioprine or cyclosporine
Authorization may alternatively be granted for adult members who have previously received a targeted synthetic drug (e.g., Litfulo, Olumiant) indicated for treatment of severe alopecia areata in the past year

Adult member using the medication for severe alopecia areata
Member achieves or maintains a positive clinical response as evidenced by improvement in signs and symptoms from baseline (e.g., increased scalp hair coverage, 80% total scalp hair coverage [SALT score ≤ 20])
Continued absence of active TB infection and adherence to TB management requirements
Medication is not used concomitantly with any other biologic drug, targeted synthetic drug, or potent immunosuppressant such as azathioprine or cyclosporine

12 months