Pharmacy Prior Authorization Criteria

Litfulo (ritlecitinib)

Indications for Prior Authorization

Litfulo (ritlecitinib)

• For diagnosis of Alopecia Areata (AA)
  Indicated for the treatment of adult and adolescent patients 12 years and older with severe alopecia areata. Not recommended for use in combination with other JAK inhibitors, biologic immunomodulators, cyclosporine or other potent immunosuppressants.

Criteria

Litfulo

*Litfulo may be used with concomitant methotrexate, topical or inhaled corticosteroids, and/or low stable dosages of oral corticosteroids (equivalent to 10 mg or less of prednisone daily).

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Alopecia Areata

• Diagnosis of alopecia areata
AND
• Patient has at least 50% scalp hair loss [1, 2]
AND
• Other causes of hair loss have been ruled out (e.g., androgenetic alopecia, trichotillomania, other scalp disease) [2]
AND
• Patient is 12 years of age or older
AND
• Prescribed by or in consultation with a dermatologist
AND
• Not used in combination with other JAK inhibitors, biologic immunomodulators, cyclosporine or other potent immunosuppressants*

Litfulo

*Litfulo may be used with concomitant methotrexate, topical or inhaled corticosteroids, and/or low stable dosages of oral corticosteroids (equivalent to 10 mg or less of prednisone daily).

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Alopecia Areata

• Documentation of positive clinical response to therapy
AND
• Not used in combination with other JAK inhibitors, biologic immunomodulators, cyclosporine or other potent immunosuppressants*

P & T Revisions

2024-09-06, 2023-11-08, 2023-11-13, 2023-11-14

References

1. Litfulo Prescribing Information. Pfizer. New York, NY. June 2023.
2. King B, Zhang X, Harcha WG, et al. Efficacy and safety of ritlecitinib in adults and adolescents with alopecia areata: a randomised, double-blind, multicentre, phase 2b-3 trial. Lancet. 2023;401(10387):1518-1529.

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Revision History

• 2024-09-06: Annual review - no criteria changes
• 2023-11-08: New Program
• 2023-11-13: New Program
• 2023-11-14: Program Update

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