Subject: Specialty Quantity Limit Cibinqo 5143-H P2025

Drug

CIBINQO  (abrocitinib)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Cibinqo (abrocitinib) 50 mg tablets	30 tablets per 30 days
Cibinqo (abrocitinib) 100 mg tablets	30 tablets per 30 days
Cibinqo (abrocitinib) 200 mg tablets	30 tablets per 30 days

FDA-recommended dosing

Atopic dermatitis

100 mg once daily

If an adequate response is not achieved, consider increasing dosage to 200 mg once daily.

Dose adjustments

Reduce to 50 mg once daily for patients:

• With moderate renal impairment (not recommended for patients with severe renal impairment).
• Who are known or suspected to be CYP2C19 poor metabolizers or who are receiving strong CYP2C19 inhibitors.
• If an adequate response is not achieved, consider increasing dosage to 100 mg once daily.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Cibinqo [package insert]. New York, NY: Pfizer Inc.; December 2023.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

April 20, 2025