Limited coverage criteria – upadacitinib

upadacitinib

15 mg, 30 mg extended release tablets

Initial

For the treatment of patients 12 years of age and older with moderate to severe atopic dermatitis (AD) if the following criteria are met:

Patient has had treatment failure despite an adequate trial of the following therapies:

• Maximally tolerated medical topical therapies for AD combined with phototherapy (where available), AND
• Maximally tolerated medical topical therapies for AD combined with at least 2 of the 4 systemic immunomodulators (methotrexate, cyclosporine, mycophenolate mofetil, or azathioprine)

AND

Patient has an Eczema Area and Severity Index (EASI)¹ score of 16 or higher and a validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD)¹ score of 3 or higher

AND

When requested by a dermatologist, allergist, or clinical immunologist who has expertise in the management of moderate to severe AD

Please note that upadacitinib will not be covered for use in combination with any other immunomodulatory agents (including biologics) or other JAK inhibitor treatment for moderate to severe AD

6 months

Renewals

Patient must attain and maintain beneficial clinical effect, defined as a 75% or greater improvement from baseline in the EASI score (EASI-75)¹

AND

When requested by a dermatologist, allergist, or clinical immunologist who has expertise in the management of moderate to severe AD

Please note that upadacitinib will not be covered for use in combination with any other immunomodulatory agents (including biologics) or other JAK inhibitor treatment for moderate to severe AD

1 year