Dupilumab (Dupixent)

OFFICE / HOME HEALTH / SELF ADMINISTRATION

Indications for Prior Authorization:

  • Treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.

Patient's must meet the following criteria for the indication(s) above:

  • Prescribed by or in collaboration with a dermatologist, AND
  • Chart note documentation required documenting diagnosis of moderate-to-severe atopic dermatitis, drugs tried and failed and reason for failure, AND
  • 18 years or older; AND
  • Member has an Investigator's Global Assessment (IGA) score of 3 or 4; AND
  • Exacerbating factors that could contribute to the member's atopic dermatitis have been evaluated and addressed (e.g., non-compliance with therapy, environmental triggers, allergy patch testing, etc.); AND
  • Tried and failed all of the following (note: failure is defined as the member being refractory to daily treatment for at least 1 month for topical corticosteroids and 6 weeks for topical calcineurin inhibitor or maximum duration recommended by the product's prescribing information:
    • At least one medium to very high potency topical corticosteroid, AND
    • At least one topical calcineurin inhibitor (Elidel, Protopic), AND
    • At least one oral DMARD (e.g., cyclosporin), AND
  • Member will not use Dupixent concomitantly with other biologics (e.g., Xolair, Remicade, Enbrel, Nucala, etc.), AND
  • Member does not have a parasitic infection

Reauthorization criteria:

  • Member has had a clinical reduction in body surface area (BSA) affected, AND
  • Member has had a clinical reduction in pruritus and flares, AND
  • Member has had an improvement of at least 2 points on the IGA from initiation of treatment, AND
  • Member will not use Dupixent concomitantly with other biologics (e.g., Xolair, Remicade, Enbrel, Nucala, et.c)

Dosing:

  • Initial dose of 600mg (two 300mg injections), followed by 300mg given every other week
  • Dupixent can be used with or without topical corticosteroids
  • If a dose is missed, the patient should administer the injection within 7 days from the missed dose and then resume the patient's original schedule.  If the missed dose is not administered within 7 days, the patient should wait until the next dose on the original schedule

Approval:

  • Initial: 4 months
  • Renewal: 1 year

Last review date: June 12, 2017

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