Cibinqo — Medical Mutual

Atopic Dermatitis

Initial criteria

Patient is age ≥ 12 years
Patient has moderate-to-severe atopic dermatitis with at least one of the following: involvement of ≥ 10% of body surface area (BSA) OR Eczema Area and Severity Index (EASI) score ≥ 16 OR Investigator’s Global Assessment (IGA) score ≥ 3 OR Scoring Atopic Dermatitis (SCORAD) score ≥ 25 OR incapacitation due to AD lesion location
Medication is prescribed by or in consultation with an allergist, immunologist, or dermatologist
Patient meets two of the following three conditions: (1) Did not respond adequately to (or is not a candidate for) a 3-month minimum trial of topical agents (e.g., corticosteroids, calcineurin inhibitors, crisaborole) OR (2) Did not respond adequately to (or is not a candidate for) a 3-month minimum trial of at least one systemic agent (e.g., cyclosporine, azathioprine, methotrexate, mycophenolate mofetil, oral corticosteroids) OR (3) Did not respond adequately to (or is not a candidate for) a 3-month minimum trial of phototherapy (e.g., PUVA, UVB)

Patient has already received at least 180 days of therapy with Cibinqo
Patient experienced a beneficial clinical response, defined as improvement from baseline in at least one of the following: estimated body surface area affected, erythema, induration/papulation/edema, excoriations, lichenification, OR a decreased requirement for other topical or systemic therapies
Compared with baseline, patient experienced an improvement in at least one symptom, such as decreased itching

initial 6 months; reauth 1 year