Pharmacy Prior Authorization Criteria

Anzupgo (delgocitinib)

Indications for Prior Authorization

Anzupgo (delgocitinib)

• For diagnosis of Chronic Hand Eczema (CHE)
  Indicated for the topical treatment of moderate to severe chronic hand eczema (CHE) in adults who have had an inadequate response to, or for whom topical corticosteroids are not advisable.

Criteria

Anzupgo

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Chronic Hand Eczema (CHE)

• Diagnosis of moderate to severe chronic hand eczema (CHE)
AND
• Patient is 18 years of age or older
AND
• Prescribed by or in consultation with one of the following:
• Dermatologist
• Allergist/Immunologist
AND
• Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to BOTH of the following [1-3]:
• Medium or higher potency topical corticosteroid
• Generic calcineurin inhibitor (e.g., tacrolimus ointment)
AND
• Not used in combination with other Janus kinase (JAK) inhibitors or potent immunosuppressants (e.g., azathioprine or cyclosporine)

Anzupgo

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Chronic Hand Eczema (CHE)

• Patient demonstrates positive clinical response to therapy (e.g., erythema, scaling, hyperkeratosis, fissures) [1-3]
AND
• Not used in combination with other JAK inhibitors or potent immunosuppressants (e.g., azathioprine or cyclosporine)

P & T Revisions

2025-09-11

References

1. Anzupgo prescribing information. LEO Pharma Inc. Madison, NJ. July 2025.
2. Bissonnette R, Warren RB, Pinter A, et al. Efficacy and safety of delgocitinib cream in adults with moderate to severe chronic hand eczema (DELTA 1 and DELTA 2): results from multicentre, randomised, controlled, double-blind, phase 3 trials. Lancet. 2024; 404(10451):461-473.
3. Thyssen JP, Schuttelaar MLA, Alfonso JH, et al. Guidelines for diagnosis, prevention, and treatment of hand eczema. Contact Dermatitis. 2022; 86(5):357-378.
4. Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023;89(1):e1-e20.

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Revision History

• 2025-09-11: New program

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