Olumiant — Medical Mutual

Alopecia Areata

Initial criteria

Patient is age ≥ 18 years; AND
Patient has a current episode of alopecia areata lasting for ≥ 6 months; AND
Patient has ≥ 50% scalp hair loss; AND
Patient has tried at least one of the following for alopecia areata: conventional systemic therapy (e.g., corticosteroids, methotrexate, cyclosporine) OR topical corticosteroid; AND
Patient does not have hair loss due to androgenetic alopecia, chemotherapy-induced hair loss, or other causes of hair loss other than alopecia areata; AND
The medication is prescribed by or in consultation with a dermatologist

Patient is age ≥ 18 years; AND
Patient has been established on the requested drug for at least 6 months; AND
Patient experienced a beneficial clinical response, defined as improvement from baseline in extent and density of scalp hair loss; AND
According to the prescriber, the patient continues to require systemic therapy for treatment of alopecia areata

initial: 6 months; reauth: 1 year