CurrentColorado Rocky Mountain Health PlansPolicy N/A

Dupixent (dupilumab) prior authorization for Eosinophilic Esophagitis

Prior authorization form and requirements for Dupixent (dupilumab) to treat eosinophilic esophagitis for Colorado Rocky Mountain Health Plans members; directed at prescribers requesting initiation or continuation of therapy.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDupixent (dupilumab) prior authorization for Eosinophilic Esophagitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including age, diagnosis, prior therapy history, and provide medical records documenting ongoing benefit for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age ≥ 12minimum beneficiary age asked on form

Documented benefit requiredcontinuation requires medical records showing clinical benefit

Therapy length optionspreset length-of-therapy choices on form

Pediatric boundary notedform explicitly asks if patient is 12 years or older

Coverage Criteria

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inv-01: Initial and Continuation Therapy

Covered when ALL of the following are met (as indicated on the form):

Initial request criteria: Patient is age 12 years or older; patient has a diagnosis of eosinophilic esophagitis; and patient has tried and failed or has a contraindication or intolerance to proton pump inhibitors or topically delivered steroids.

From form fields asking age, diagnosis, and prior therapy

Continuation request criteria: While on Dupixent, beneficiary has had continued clinical benefit from baseline supported by medical records provided with the request.

Form requires submission of medical records documenting current disease status and response

No explicit exclusions are listed on the Dupixent prior authorization form for eosinophilic esophagitis. The clinical-information section collects age, diagnosis, and prior-therapy history but does not enumerate any specific exclusion criteria on the form itself.

The form requires medical-record documentation to support continuation of therapy. Specifically, continuation questions ask whether the beneficiary has had continued clinical benefit from baseline supported by medical records, and the form instructs the prescriber to provide medical records documenting the beneficiary's current Eosinophilic Esophagitis status and response to Dupixent treatment. Failure to provide these records may render continuation not medically necessary.

Initial Therapy

inv-11: Initial Therapy

Initial therapy requests must confirm diagnosis, age, and prior therapy history.

Initial: Patient is 12 years or older; has a diagnosis of eosinophilic esophagitis; and has tried and failed or has contraindication/intolerance to proton pump inhibitors or steroids delivered topically (inhaler, liquid, or tablet).

Derived from clinical information questions on the form

Continuation of Therapy

inv-12: Continuation of Therapy

Continuation of Dupixent requires demonstration of ongoing benefit.

Continuation: Prescriber affirms that while on Dupixent the beneficiary has had continued clinical benefit from baseline supported by medical records provided with the request.

Form explicitly requests medical records documenting current Eosinophilic Esophagitis status and treatment response

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The prior authorization form must include completed beneficiary, prescriber, drug, and clinical information fields, including beneficiary identifiers (name, ID, DOB, gender), prescriber NPI and contact, drug name/strength/quantity/length of therapy, and answers to clinical questions (age ≥12, diagnosis of eosinophilic esophagitis, prior trial/failure or contraindication/intolerance to proton pump inhibitors or topically delivered steroids).

Beneficiary identifiers: name, ID, DOB, gender
Prescriber: NPI, contact name and phone
Drug: name, strength, quantity per 30 days, length of therapy
Clinical: age (12 years or older), diagnosis of eosinophilic esophagitis, prior therapy trial/failure or contraindication/intolerance to PPI or topical steroids

Documentation Required

Medical Records Required for Continuation

For continuation/renewal requests, the prescriber must provide medical records documenting the beneficiary's current eosinophilic esophagitis status and the clinical response/continued benefit from Dupixent compared with baseline. Failure to include these records may result in denial or delay of the request.

Medical records must show current disease status and documented clinical benefit from Dupixent versus baseline
Attach progress notes, endoscopy/pathology reports, symptom scores, or other objective documentation as applicable

Denial Risk

Missing Documentation May Result in Denial or Delay

If medical records documenting current disease status and response to therapy are not provided with a continuation request, the request may be denied or a peer-to-peer/medical review may be requested. Ensure timely submission of requested documentation to avoid interruption of therapy.

Missing documentation for continuation risks denial or delay
Be prepared to submit records promptly if follow-up is requested

Documentation Required

Form Completion Required

Complete all required form fields before submission. The form must include beneficiary, prescriber, drug, and clinical sections filled out in full and the prescriber's signature and date. Incomplete forms will not be processed and will be returned for completion.

Beneficiary, prescriber, drug, and clinical information must be completed
Prescriber signature and date required

Step	Prior therapy required before Dupixent
{"text":"1","status":""}\|{"text":"Patient must have tried and failed, or have a contraindication or intolerance to proton pump inhibitors or steroids delivered topically (inhaler, liquid, or tablet).","status":""}

Background

Eosinophilic esophagitis is queried on the form as the diagnosis for which Dupixent is being requested. The clinical section confirms whether the beneficiary has a diagnosis of Eosinophilic Esophagitis, asks that the patient be age 12 years or older, and documents prior therapy history (trial and failure or contraindication/intolerance to proton pump inhibitors or topically delivered steroids). For continuation, the form requires demonstration of ongoing benefit from baseline supported by submitted medical records.