CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Ebglyss (lebrikizumab-lbkz) for Moderate-to-Severe Atopic Dermatitis

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This policy governs pharmacy or medical prior authorization coverage of Ebglyss for CareSource Georgia Medicaid members aged 12 years and older who weigh at least 40 kg and have moderate-to-severe atopic dermatitis. It defines initial authorization, dosing, quantity limits, reauthorization, and non-medically-necessary indications.

Policy Summary

PayerCareSource Georgia

PolicyEbglyss (lebrikizumab-lbkz) for Moderate-to-Severe Atopic Dermatitis

Policy CodePolicy GA-MED-P-366579

Change TypeNew policy

Effective DateFeb 1, 2026

Last ReviewOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis, disease severity, and failure of one qualifying prior-treatment pathway.

SourceLink

POLICY UPDATE CHANGES

A new policy for Ebglyss (lebrikizumab-lbkz) was created on October 1, 2024.

Age 12+; ≥40 kgInitial eligibility threshold

≥10% BSA or critical-area diseaseDisease severity requirement

4 monthsInitial approval duration

12 months

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CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Ebglyss (lebrikizumab-lbkz) for Moderate-to-Severe Atopic Dermatitis

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Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

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Policy Summary

PayerCareSource Georgia

PolicyEbglyss (lebrikizumab-lbkz) for Moderate-to-Severe Atopic Dermatitis

Policy CodePolicy GA-MED-P-366579

Change TypeNew policy

Effective DateFeb 1, 2026

Last ReviewOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis, disease severity, and failure of one qualifying prior-treatment pathway.

SourceLink

POLICY UPDATE CHANGES

A new policy for Ebglyss (lebrikizumab-lbkz) was created on October 1, 2024.

Age 12+; ≥40 kgInitial eligibility threshold

≥10% BSA or critical-area diseaseDisease severity requirement

4 monthsInitial approval duration

12 months

Reauthorization duration

1 pen/syringe per 28 daysMaintenance quantity limit

Not medically necessaryUnlisted conditions

Coverage Criteria

Initial Therapy

Ebglyss is covered for initial therapy when ALL of the following criteria are met:

ALL of the following

Member is at least 12 years of age and weighs at least 40 kg.
Medication is prescribed by or in consultation with a dermatologist, allergist, or immunologist.
Member has a diagnosis of moderate to severe atopic dermatitis (AD).
Member's AD involves 10% or more of the body surface area (BSA) OR involves highly visible or functional areas (e.g., neck, face, genitals, or palms) and significantly impairs quality of life.
ONE of the following qualifying prior-treatment pathways
- Documented trial and failure of two trials of medium- to very-high-potency topical corticosteroids, each for 2 weeks. A topical calcineurin inhibitor (e.g., tacrolimus or pimecrolimus) for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
- Documented trial and failure of at least 8 weeks of phototherapy (UV-A, UV-B, a combination of both, or UV-B1 [narrow-band UV-B]) AND one trial of medium- to very-high-potency topical corticosteroids for 2 weeks. A topical calcineurin inhibitor (e.g., tacrolimus or pimecrolimus) for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
- Documented trial and failure of one 12-week trial of an oral immunomodulatory agent (e.g., cyclosporine, methotrexate, or azathioprine) AND one trial of medium- to very-high-potency topical corticosteroids for 2 weeks. A topical calcineurin inhibitor (e.g., tacrolimus or pimecrolimus) for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.

Continuation Therapy

Reauthorization requires the following:

ALL of the following

Chart notes demonstrate improvement in signs and symptoms, such as fewer flares, less itching or erythema, or improved quality of life.
If the requirement above is met, the medication will be approved for an additional 12 months.

Conditions or indications not listed in this document are excluded from medical necessity consideration. For any other indication, refer to the Off-Label policy.

CareSource considers Ebglyss (lebrikizumab-lbkz) not medically necessary for the treatment of conditions or indications that are not listed in this document.

Eligibility and Trial Thresholds

Minimum age

Minimum ageAt least 12 years

Applies toAdults and pediatric patients seeking Ebglyss for moderate-to-severe atopic dermatitis

Authorization contextRequired for initial authorization

Minimum body weight

Minimum body weightAt least 40 kg

Applies toMembers seeking Ebglyss for moderate-to-severe atopic dermatitis

Authorization contextRequired for initial authorization

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Ebglyss (lebrikizumab-lbkz), whether processed through the pharmacy or medical benefit.

Step Therapy

Documented Failure of Prior Therapy

For initial authorization, document a qualifying failure of prior therapy for moderate-to-severe atopic dermatitis. The member must have failed ONE of the treatment pathways below.

Two trials of medium- to very-high-potency topical corticosteroids for 2 weeks. A topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
At least 8 weeks of phototherapy (UV-A, UV-B, combined UV-A/UV-B, or narrow-band UV-B) AND one trial of a medium- to very-high-potency topical corticosteroid for 2 weeks. A topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
One 12-week trial of an oral immunomodulatory agent, such as cyclosporine, methotrexate, or azathioprine, AND one trial of a medium- to very-high-potency topical corticosteroid for 2 weeks. A topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.

Therapy Background

Ebglyss (lebrikizumab-lbkz) is an interleukin-13 antagonist indicated for adults and pediatric patients aged 12 years and older who weigh at least 40 kg and have moderate-to-severe atopic dermatitis. It is used when the disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable, and it may be used with or without topical corticosteroids.

Clinical Definitions

Significant moderate-to-severe atopic dermatitis involvement

BSA involvement10% or more of the body surface area

Highly visible or functional areasNeck, face, genitals, or palms

Quality-of-life impactDisease involving these areas must significantly impair quality of life

Initial Authorization

Initial Authorization Criteria

Covered for initial authorization when ALL clinical criteria are met and the member has documented trial and failure of ONE qualifying prior-treatment pathway.

Initial Ebglyss authorization

Clinical criteria
- Member is at least 12 years of age and weighs at least 40 kg.Age ≥12 years; weight ≥40 kg
- Medication is prescribed by or in consultation with a dermatologist, allergist, or immunologist.
- Member has a diagnosis of moderate-to-severe atopic dermatitis.

Reauthorization

Reauthorization Criteria

Reauthorization requires documented clinical improvement.

Reauthorization

Chart notes demonstrate improvement in signs and symptoms, such as fewer flares, less itching or erythema, or improved quality of life.Clinical improvement documented in chart notes
If met, authorization is extended for an additional 12 months.

Qualifying Prior-Treatment Pathways

Pathway	Required documented trial and failure	Duration	Acceptable topical alternatives
Topical corticosteroid pathway	Two trials of medium- to very-high-potency topical corticosteroids	2 weeks	Topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
Phototherapy pathway	Phototherapy plus one trial of a medium- to very-high-potency topical corticosteroid	Phototherapy for at least 8 weeks plus topical corticosteroid trial for 2 weeks	Topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
Oral immunomodulatory pathway	One trial of an oral immunomodulatory agent plus one trial of a medium- to very-high-potency topical corticosteroid	Oral immunomodulator for 12 weeks plus topical corticosteroid trial for 2 weeks	Topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.

Dosing and Quantity Limits

Ebglyss quantity limit

Quantity limit1 pen or syringe

Supply intervalPer 28 days

When it appliesAfter loading doses

Policy Summary

PayerCareSource Georgia

PolicyEbglyss (lebrikizumab-lbkz) for Moderate-to-Severe Atopic Dermatitis

Policy CodePolicy GA-MED-P-366579

Change TypeNew policy

Effective DateFeb 1, 2026

Last ReviewOct 1, 2024

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis, disease severity, and failure of one qualifying prior-treatment pathway.

SourceLink

On This Page

Body surface area involvement

BSA thresholdAt least 10% of body surface area

Alternative severity criterionHighly visible or functional area involvement, including the neck, face, genitals, or palms

Additional requirement for critical-area diseaseSignificant impairment of quality of life

Phototherapy trial

Required durationAt least 8 weeks of phototherapy

Acceptable modalitiesUV-A, UV-B, combined UV-A/UV-B, or UV-B1 (narrow-band UV-B)

Additional prior-treatment requirementOne trial of a medium- to very-high-potency topical corticosteroid for 2 weeks

Oral immunomodulatory trial

Required durationOne 12-week trial

Acceptable agentsOral immunomodulatory agents such as cyclosporine, methotrexate, or azathioprine

Additional prior-treatment requirementOne trial of a medium- to very-high-potency topical corticosteroid for 2 weeks

Topical calcineurin inhibitor trial

Required duration6 weeks

Acceptable agentsTopical calcineurin inhibitors such as tacrolimus or pimecrolimus

Use in prior-treatment documentationMay be acceptable as an alternative to the specified topical corticosteroid trial

Eucrisa trial

Required duration4 weeks

TreatmentEucrisa

Use in prior-treatment documentationMay be acceptable as an alternative to the specified topical corticosteroid trial

Opzelura trial

Required duration8 weeks

TreatmentOpzelura

Use in prior-treatment documentationMay be acceptable as an alternative to the specified topical corticosteroid trial

Documentation Required

Initial Authorization Clinical Documentation

Submit clinical documentation supporting all initial authorization requirements for Ebglyss.

Member is at least 12 years of age and weighs at least 40 kg.
Prescription is written by, or provided in consultation with, a dermatologist, allergist, or immunologist.
Diagnosis of moderate-to-severe atopic dermatitis is documented.
Atopic dermatitis involves at least 10% of body surface area (BSA), OR involves a highly visible or functional area—such as the neck, face, genitals, or palms—and significantly impairs quality of life.

Documentation Required

Reauthorization Response Documentation

For reauthorization, provide chart notes demonstrating that the member has clinically improved with Ebglyss. If requirements remain satisfied, authorization may be extended for an additional 12 months.

Document improvement in signs and symptoms, such as fewer flares, less itching or erythema, and improved quality of life.

Denial Risk

Denial Risk: Criteria or Indication Not Met

Coverage may be denied when the clinical criteria are not met or when Ebglyss is requested for a condition or indication not listed in this policy.

Requests for an unlisted or other indication are considered not medically necessary under this policy; refer to the Off-Label policy for those requests.

Atopic dermatitis involves at least 10% of body surface area (BSA), or involves highly visible or functional areas such as the neck, face, genitals, or palms and significantly impairs quality of life.

BSA ≥10% or qualifying critical-area disease

ONE qualifying prior-treatment pathway

Topical corticosteroid pathway
- Two trials of medium- to very-high-potency topical corticosteroids for 2 weeks.Two trials; 2 weeks
  A topical calcineurin inhibitor such as tacrolimus or pimecrolimus for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
Phototherapy pathway
- At least 8 weeks of phototherapy, including UV-A, UV-B, combined UV-A/UV-B, or narrow-band UV-B.Phototherapy ≥8 weeks
- One trial of a medium- to very-high-potency topical corticosteroid for 2 weeks.One trial; 2 weeks
  A topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.
Oral immunomodulatory pathway
- One 12-week trial of an oral immunomodulatory agent such as cyclosporine, methotrexate, or azathioprine.12 weeks
- One trial of a medium- to very-high-potency topical corticosteroid for 2 weeks.One trial; 2 weeks
  A topical calcineurin inhibitor for 6 weeks, Eucrisa for 4 weeks, or Opzelura for 8 weeks may also be acceptable.