Litfulo (ritlecitinib) — CareFirst (Caremark)

Severe alopecia areata in adults and adolescents age ≥ 12 years

Preferred products

Member is age ≥ 12 years
Prescribed by or in consultation with a dermatologist
Member has at least 50% scalp hair loss (e.g., Severity of Alopecia Tool [SALT] score of 50 or higher)
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 (e.g., tuberculosis skin test [TST] or interferon-release assay [IGRA]) within 12 months of initiating therapy for persons naïve to biologic or targeted synthetic drugs associated with increased risk of TB
If TB screening test is positive, further testing confirms no active disease (e.g., chest x-ray); if latent disease present, TB treatment must start before initiating Litfulo
Medication will not be used concomitantly with another biologic drug, targeted synthetic drug, or potent immunosuppressant (e.g., azathioprine or cyclosporine)
Authorization of 12 months may be granted for members who previously received a targeted synthetic drug (e.g., Leqselvi, Olumiant) indicated for severe alopecia areata in the past year OR meet the criteria above

Member is age ≥ 12 years
Member continues to use the medication for severe alopecia areata
Member has achieved or maintained positive clinical response as evidenced by improvement in signs and symptoms (e.g., increased scalp hair coverage, 80% total scalp hair coverage [SALT score of 20 or less])

12 months