Cibinqo (abrocitinib) — Highmark

Atopic dermatitis

Initial criteria

age ≥ 12 years
Diagnosis of atopic dermatitis (ICD-10: L20) that is moderate-to-severe AND refractory, attested by dermatologist, allergist, or immunologist
Member has experienced therapeutic failure or intolerance to ONE (1) of the following: ONE (1) generic topical corticosteroid OR ONE (1) generic topical calcineurin inhibitor (tacrolimus or pimecrolimus) OR prescriber documents member has severe atopic dermatitis and topical therapy would not be advisable for maintenance therapy because member is incapable of applying topical therapies due to extent of body surface area involvement OR topical therapies are contraindicated due to severely damaged skin
Member has experienced therapeutic failure or intolerance to ONE (1) systemic therapy for atopic dermatitis, OR all systemic therapies are contraindicated
If the patient has already had a trial of at least one (1) biologic agent for the same indication, the patient is not required to step back and try a nonbiologic agent

Prescriber attests that the member has experienced a positive clinical response to therapy

12 months