Olumiant — CareFirst (Caremark)

severe alopecia areata

Initial criteria

age ≥ 18 years
Member has previously received a targeted synthetic drug (e.g., Leqselvi, Litfulo) indicated for treatment of severe alopecia areata in the past year OR meets both of the following:
• 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 within 12 months of initiating therapy if naïve to biologic or targeted synthetic drugs associated with increased TB risk
If TB screening is positive, active disease must be ruled out (e.g., chest x-ray); members with active TB infection must not receive therapy; latent disease must be treated before initiation
Medication is not used concomitantly with any other biologic drug, targeted synthetic drug, or potent immunosuppressant such as azathioprine or cyclosporine
Prescribed by or in consultation with a dermatologist

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])

12 months