CurrentAvMedPolicy N/A

Nemluvio

Pharmacy prior authorization and step-edit criteria for Nemluvio (nemolizumab-ilto) covering indications, required baseline documentation, required prior trials/therapies, dosing, quantity limits, prescriber qualifications, and reauthorization requirements for Prurigo Nodularis and Atopic Dermatitis.

Policy Summary

PayerAvMed

PolicyNemluvio

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign the PA request and submit chart notes, recent weight, PP-NRS, lesion counts, prior therapy documentation and pharmacy paid claims; fax to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

2Indications covered (Prurigo Nodularis; Atopic Dermatitis)

1/28dQuantity limit

>=7PP-NRS approval threshold

>=20Lesion count requirement for PN

Coverage Summary

Scope: Pharmacy prior authorization and step-edit policy for Nemluvio (nemolizumab‑ilto) covering Prurigo Nodularis and Moderate‑to‑Severe Atopic Dermatitis. Required prescriber specialty is an allergist, dermatologist, or immunologist. Recommended dosing by weight: for patients <90 kg, a 60 mg subcutaneous dose followed by 30 mg every 4 weeks; for patients ≥90 kg, 60 mg followed by 60 mg every 4 weeks. Initial authorization durations: 6 months for Prurigo Nodularis and 4 months for Atopic Dermatitis. Reauthorization options include 12 months for Prurigo Nodularis and maintenance dosing adjustments (e.g., reduction to 30 mg every 8 weeks after response) for Atopic Dermatitis. Quantity limit is 1 pen per 28 days.

Key thresholds and limits

PP-NRS threshold>= 7

Prurigo nodularis lesion count>= 20 lesions

Prurigo nodularis disease duration>= 3 months

Atopic dermatitis BSA>= 10%

EASI score>= 16

IGA score>= 3

SCORAD score>= 25

Quantity limit1 pen per 28 days

Covered indications2 (Prurigo Nodularis; Moderate-to-Severe Atopic Dermatitis)