Subject: Specialty Quantity Limit Olumiant 2602-H P2025

Drug

OLUMIANT  (baricitinib)

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
Olumiant (baricitinib) 1 mg tablet	30 per 30 days
Olumiant (baricitinib) 2 mg tablet	30 per 30 days
Olumiant (baricitinib) 4 mg tablet	30 per 30 days

FDA-recommended Dosing

Rheumatoid arthritis (adult)

2 mg once daily.

• Reduce dose to 1 mg daily for moderate renal impairment.
• Not recommended for severe renal impairment.

Alopecia areata (adult)

2 mg once daily.

• Increase to 4 mg once daily if the response to treatment is not adequate.
• For patients with nearly complete or complete scalp hair loss, with or without substantial eyelash or eyebrow hair loss, consider treating with 4 mg once daily.
• Reduce the dose to 2 mg once daily when an adequate response has been achieved.
• For moderate renal impairment, reduce to 1 mg once daily if the recommended dosage is 2 mg once daily and reduce to 2 mg once daily if the recommended dosage is 4 mg once daily.
• Not recommended for severe renal impairment.
• Co-administration with strong organic anion transporter (OAT3) inhibitors (e.g., probenecid)
• If the recommended dosage is 4 mg once daily, reduce dosage to 2 mg once daily.
• If the recommended dosage is 2 mg once daily, reduce dosage to 1 mg once daily.
• If the recommended dosage is 1 mg once daily, consider discontinuing concomitant strong OAT3 inhibitor.

Note: The criteria outlined in this policy is only applicable to coverage in the outpatient setting. Hospitalized members receiving Olumiant for the treatment of coronavirus disease 2019 (COVID-19) will be managed according to the member’s inpatient benefit.

Place of Service:

Outpatient

The above policy is based on the following references:

Olumiant [package insert]. Indianapolis, IN: Lilly USA, LLC; June 2022.

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