CurrentHawaii Medical Service Association (HMSA)Policy N/A

Dupixent (dupilumab) Coverage and Prior Authorization

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This policy governs HMSA coverage and authorization requirements for Dupixent (dupilumab) for specified FDA-approved and compendial indications. It applies to HMO and PPO members and requires indication-specific clinical criteria, documentation, prescriber qualifications, and continuation requirements.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyDupixent (dupilumab) Coverage and Prior Authorization

Policy CodePolicy N/A

Change TypeAdministrative applicability update

Effective DateJul 1, 2026

Last ReviewJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with clinical documentation applicable to the requested indication and evidence that all approval criteria are met.

SourceLink

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CurrentHawaii Medical Service Association (HMSA)Policy N/A

Dupixent (dupilumab) Coverage and Prior Authorization

Customize your policy alerts

Sign up for all Hawaii Medical Service Association (HMSA) policy alerts

Know when Hawaii Medical Service Association (HMSA) releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyDupixent (dupilumab) Coverage and Prior Authorization

Policy CodePolicy N/A

Change TypeAdministrative applicability update

Effective DateJul 1, 2026

Last ReviewJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with clinical documentation applicable to the requested indication and evidence that all approval criteria are met.

SourceLink

POLICY UPDATE CHANGES

The document history records removal of the QUEST line of business from the policy effective July 1, 2026.

8Covered indication categories

6 months to adultAge range

4–12 monthsInitial authorization periods

12 monthsReauthorization period

RequiredPrior authorization

Coverage Criteria

Initial Therapy: Atopic Dermatitis

Covered when either of the following pathways is met:

ONE of the following

Member is 6 months of age or older and has previously received a biologic (e.g., Adbry, Ebglyss, Nemluvio) or systemic targeted synthetic drug (e.g., Cibinqo, Rinvoq) indicated for moderate-to-severe atopic dermatitis in the past 180 days.
ALL of the following
- Member is 6 months of age or older with moderate-to-severe atopic dermatitis and an affected body surface area of at least 10% or involvement of crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas).
- ONE of the following
  - Member has had an inadequate treatment response to two of the following in the past 180 days: a high- or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, or topical PDE-4 inhibitor.
  - Use of a high- or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, and topical PDE-4 inhibitor is not advisable for the member (e.g., due to contraindications, prior intolerance, or potency not appropriate for the member's age).

Initial Therapy: Asthma

Covered when either the qualifying prior-therapy pathway or all disease and treatment criteria are met:

ONE of the following

Member is 6 years of age or older and has previously received a biologic drug indicated for asthma (e.g., Nucala, Cinqair) in the past year.
ALL of the following
- Member is 6 years of age or older with moderate-to-severe asthma and has uncontrolled asthma, demonstrated by at least one of the following within the past year: two or more asthma exacerbations requiring oral or injectable corticosteroid treatment; one or more exacerbations resulting in hospitalization or emergency medical care; or poor symptom control (frequent symptoms or reliever use, activity limited by asthma, or night waking due to asthma).
- ONE of the following
  - ALL of the following

Initial Therapy: Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)

Authorization of 6 months may be granted when all of the following criteria are met:

ALL of the following

Member is 12 years of age or older and has bilateral nasal polyposis and chronic symptoms of sinusitis despite intranasal corticosteroid treatment for at least 4 weeks, unless contraindicated or not tolerated.
ONE of the following
- Member has undergone prior sinonasal surgery.
- Prior treatment with systemic corticosteroids within the last two years was ineffective, unless contraindicated or not tolerated.
ONE of the following objective findings
- Bilateral nasal endoscopy, anterior rhinoscopy, or computed tomography shows polyps reaching below the lower border of the middle turbinate or beyond in each nostril.

Initial Therapy: Eosinophilic Esophagitis

Authorization of 6 months may be granted when all of the following criteria are met:

ALL of the following

Member is 1 year of age or older and weighs at least 15 kg.
Member is experiencing symptoms of esophageal dysfunction (e.g., dysphagia, food impaction, vomiting, abdominal pain, food refusal, or failure to thrive).
Diagnosis has been confirmed by esophageal biopsy showing at least 15 intraepithelial esophageal eosinophils per high-power field.
Member has had an inadequate treatment response to a proton pump inhibitor or swallowed topical corticosteroid therapy (e.g., budesonide or fluticasone), unless contraindicated or not tolerated.

Initial Therapy: Prurigo Nodularis

Authorization of 6 months may be granted when all of the following criteria are met:

ALL of the following

Member is 18 years of age or older.
Member has pruritus lasting at least 6 weeks.
Member has a history or signs of a repeated itch-scratch cycle (e.g., scratching, picking, or rubbing).
Member has a minimum of 20 nodular lesions.
ONE of the following
- Member has had an inadequate response to a medium- to super-high-potency topical corticosteroid, topical calcineurin inhibitor, phototherapy (e.g., UVB or PUVA), or pharmacologic treatment with methotrexate or cyclosporine.

Initial Therapy: Chronic Obstructive Pulmonary Disease (COPD)

Authorization of 12 months may be granted when either the qualifying prior-therapy pathway or all disease and treatment criteria are met:

ONE of the following

Member is 18 years of age or older and has previously received a biologic drug indicated for COPD (e.g., Nucala) in the past year.
ALL of the following
- Diagnosis has been confirmed by spirometry showing post-bronchodilation FEV1/FVC less than 0.7.
- Member demonstrates classic signs or symptoms of COPD (e.g., dyspnea, wheezing, chest tightness, fatigue, activity limitation, cough with or without sputum production, or chronic bronchitis).
- Absolute blood eosinophil count is at least 300 cells per microliter before initiating the requested medication.
- ONE of the following

Initial Therapy: Chronic Spontaneous Urticaria

Authorization of 6 months may be granted when all of the following criteria are met:

ALL of the following

Member is 12 years of age or older and remains symptomatic despite up-dosing, in accordance with EAACI/GA2LEN/EuroGuiDerm/APAAACI guidelines, of a second-generation H1 antihistamine (e.g., cetirizine, fexofenadine, levocetirizine, or loratadine) for at least 2 weeks.
Member has been evaluated for other causes of wheals (hives) and/or angioedema, including bradykinin-related angioedema and interleukin-1-associated urticarial syndromes (autoinflammatory disorders or urticarial vasculitis).
Member has experienced spontaneous onset of wheals (hives), angioedema, or both for at least 6 weeks.

Initial Therapy: Immune Checkpoint Inhibitor-Related Toxicity

Authorization of 12 months may be granted when the requested medication is used for an applicable immune checkpoint inhibitor-related toxicity and the applicable criterion below is met:

ONE of the following

Severe (G3) pruritus with no response to gabapentinoids in one month.
ALL of the following
- Requested medication will be used as additional therapy for bullous pemphigoid.
- ANY of the following
  - Moderate (G2) bullous dermatitis when the diagnosis is bullous pemphigoid.
  - Severe (G3) or life-threatening (G4) bullous dermatitis.

Continuation Therapy: Atopic Dermatitis

Authorization of 12 months may be granted when both of the following are met:

ALL of the following

Member is 6 months of age or older and was previously authorized by HMSA/CVS.
Member achieves or maintains a positive clinical response, evidenced by low disease activity (clear or almost clear skin) or improvement in signs and symptoms of atopic dermatitis (e.g., redness, itching, or oozing/crusting).

Continuation Therapy: Asthma

Authorization of 12 months may be granted when both of the following criteria are met:

ALL of the following

Member is 6 years of age or older and was previously authorized by HMSA/CVS.
Asthma control has improved on Dupixent, demonstrated by a reduction in the frequency or severity of symptoms or exacerbations, or a reduction in the daily maintenance oral corticosteroid dose; and the member will continue to use maintenance asthma treatments (inhaled corticosteroid and additional controller) in combination with Dupixent.

Continuation Therapy: Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)

Authorization of 12 months may be granted when both of the following are met:

ALL of the following

Member is 12 years of age or older and was previously authorized by HMSA/CVS.
Member has achieved or maintained a positive clinical response with Dupixent, evidenced by improvement in signs and symptoms of CRSwNP (e.g., nasal congestion, nasal polyp size, loss of smell, anterior or posterior rhinorrhea, sinonasal inflammation, hyposmia, facial pressure or pain, or reduced corticosteroid use).
Member will continue to use a daily intranasal corticosteroid while being treated with Dupixent, unless contraindicated or not tolerated.

Asthma Reauthorization

Authorization of 12 months may be granted when both of the following criteria are met:

ALL of the following

Member is 6 years of age or older and was previously authorized by HMSA/CVS.
Asthma control has improved on Dupixent, demonstrated by at least one of the following: reduction in the frequency or severity of symptoms and exacerbations, or reduction in the daily maintenance oral corticosteroid dose.
Member will continue to use maintenance asthma treatments (inhaled corticosteroid and additional controller) in combination with Dupixent.

Chronic Rhinosinusitis with Nasal Polyposis Reauthorization

Authorization of 12 months may be granted when both of the following criteria are met:

ALL of the following

Member is 12 years of age or older and was previously authorized by HMSA/CVS.
Member has achieved or maintained a positive clinical response with Dupixent, evidenced by improvement in signs and symptoms of CRSwNP (e.g., nasal congestion, nasal polyp size, loss of smell, anterior or posterior rhinorrhea, sinonasal inflammation, hyposmia, facial pressure or pain, or reduced corticosteroid use).
Member will continue to use a daily intranasal corticosteroid while being treated with Dupixent, unless contraindicated or not tolerated.

Eosinophilic Esophagitis Reauthorization

Authorization of 12 months may be granted when all of the following criteria are met:

ALL of the following

Member is 1 year of age or older, weighs at least 15 kg, and was previously authorized by HMSA/CVS.
Member has achieved or maintained a positive clinical response with Dupixent, evidenced by improvement in signs and symptoms of eosinophilic esophagitis (e.g., dysphagia, heartburn, chest pain, or emesis).

Prurigo Nodularis Reauthorization

Authorization of 12 months may be granted when the eligibility criterion and at least one response criterion are met:

ALL of the following

Member is 18 years of age or older and was previously authorized by HMSA/CVS.
At least ONE response criterion
- Low disease activity (clear or almost clear skin).
- Reduction in pruritus intensity and improvement in the extent and severity of nodular lesions.

Chronic Obstructive Pulmonary Disease Reauthorization

Authorization of 12 months may be granted when both of the following are met:

ALL of the following

Member is 18 years of age or older and was previously authorized by HMSA/CVS.
Member has achieved or maintained a positive clinical response, evidenced by improvement in signs and symptoms of COPD (e.g., decreased exacerbations or improved pre-bronchodilator FEV1) or stabilization of disease.
Member will continue to use maintenance COPD treatments (e.g., inhaled corticosteroid with long-acting muscarinic antagonist and long-acting beta2-agonist, or long-acting muscarinic antagonist and long-acting beta2-agonist) in combination with Dupixent.

Chronic Spontaneous Urticaria Reauthorization

Authorization of 12 months may be granted when both eligibility and response requirements are met:

ALL of the following

Member is 12 years of age or older and was previously authorized by HMSA/CVS.
Member has experienced a positive clinical response since initiation of therapy (e.g., improved symptoms or decreased weekly urticaria activity score [UAS7]).

Immune Checkpoint Inhibitor-Related Toxicities Reauthorization

Authorization of 12 months may be granted for members previously authorized by HMSA/CVS when the applicable toxicity and response criteria are met:

Applicable toxicity pathway

ALL of the following
- Member was previously authorized for severe (G3) pruritus.
- Member achieves or maintains a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms of the condition.
ALL of the following
- Member was previously authorized for bullous dermatitis.
- ANY of the following

Acute bronchospasm and status asthmaticus are not covered uses of Dupixent.

Forms of urticaria other than chronic spontaneous urticaria are not covered uses of Dupixent.

For all indications, the member cannot use Dupixent concomitantly with any other biologic drug or targeted synthetic drug for the same indication.

Clinical Thresholds and Coding Details

Atopic dermatitis affected area

Body surface areaAt least 10% body surface area

Alternative criterionInvolvement of crucial body areas

Examples of crucial areasHands, feet, face, neck, scalp, genitals/groin, or intertriginous areas

Asthma eosinophil threshold

Minimum countAt least 150 cells per microliter

MeasurementBaseline blood eosinophil count

Treatment contextMeasured before initiating Dupixent therapy

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Submission

Submit the required clinical information to initiate HMSA's Dupixent prior authorization review, including indication-specific diagnosis, treatment history, response, and continuation documentation as applicable.

Include chart notes, medical records, or claims history supporting the requested indication and prior therapies.
Document drug, dose, frequency, duration, response, and any clinical reason therapy was not advisable when applicable.
For continuation requests, document positive clinical response or improvement.

Prior Authorization

Qualified Specialist Prescriber

Dupixent must be prescribed by, or used in consultation with, a qualified specialist applicable to the requested indication.

Dermatologist: atopic dermatitis, prurigo nodularis, immune checkpoint inhibitor-related toxicity, or CSU.
Allergist/immunologist: atopic dermatitis, asthma, CRSwNP, EoE, PN, COPD, or CSU.

Policy Background

Dupixent (dupilumab) is covered for multiple type 2 inflammatory and related conditions, including atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, prurigo nodularis, COPD with an eosinophilic phenotype, chronic spontaneous urticaria, and selected immune checkpoint inhibitor-related toxicities. Coverage requires indication-specific evidence of disease severity or inadequate control, appropriate prior therapy or a documented reason that prior therapy is not advisable, and demonstrated clinical response for continued treatment.

Definitions and Abbreviations

Baseline blood eosinophil count

DefinitionA blood eosinophil count measured before initiating Dupixent therapy

SpecimenBlood

TimingBefore therapy initiation

CRSwNP

AbbreviationCRSwNP

Full termChronic rhinosinusitis with bilateral nasal polyps

Required featuresSpecified symptoms, prior-treatment history, and objective polyp findings

Initial Authorization by Indication

Atopic dermatitis — 4-month initial authorization criteria

Authorization of 4 months may be granted when either initial atopic dermatitis pathway is met.

ANY of the following

Member is at least 6 months old and received a qualifying biologic or systemic targeted synthetic drug indicated for moderate-to-severe atopic dermatitis within the past 180 days.Age >= 6 months; within 180 days
Member is at least 6 months old, has affected BSA of at least 10% or crucial body-area involvement, and had an inadequate response to two qualifying topical therapies within the past 180 days or documented reasons those therapies are not advisable.BSA >= 10% or crucial body area

Asthma — 6-month initial authorization criteria

Authorization of 6 months may be granted when all criteria are met.

Continuation and Reauthorization Criteria

Atopic dermatitis reauthorization — 12-month continuation

Authorization of 12 months may be granted for previously HMSA/CVS-authorized members.

Member is at least 6 months old, was previously authorized by HMSA/CVS, and achieves or maintains positive clinical response shown by low disease activity or improvement in signs and symptoms.Age >= 6 months; authorization period 12 months

Asthma reauthorization — 12-month continuation criteria

Authorization of 12 months may be granted when both criteria are met.

ALL of the following

Member is at least 6 years old, was previously authorized by HMSA/CVS, and asthma control has improved on Dupixent.Age >= 6 years

Required Prior Treatments

Indication	Step	Required therapy	Requirement for approval	Duration
Atopic dermatitis	1	High- or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, or topical PDE-4 inhibitor	Inadequate response to two qualifying topical therapies within the past 180 days, or all listed therapies are not advisable because of contraindication, prior intolerance, or age-inappropriate potency	Past 180 days

Indication	Step	Required therapy	Requirement for approval	Duration
Asthma	1	Optimized medium- to high-dose inhaled corticosteroid plus an additional controller; alternatively, high-dose inhaled corticosteroid plus an additional controller and oral glucocorticoid	Inadequate asthma control despite therapy. In the oral glucocorticoid pathway, inhaled corticosteroid and additional controller should be used for at least 3 months, and oral glucocorticoids for most days during the prior 6 months; maintenance asthma treatments must continue with Dupixent	At least 3 months for inhaled corticosteroid and additional controller; oral glucocorticoids for most days during the prior 6 months, when applicable

Indication	Step	Required therapy	Requirement for approval	Duration
Chronic rhinosinusitis with nasal polyps	1	Intranasal corticosteroid, plus prior sino-nasal surgery or systemic corticosteroid treatment	Persistent symptoms despite intranasal corticosteroid treatment; prior systemic corticosteroid treatment must have been ineffective. The therapy may be avoided when contraindicated or not tolerated	Intranasal corticosteroid for at least 4 weeks; systemic corticosteroid treatment within the last 2 years, when applicable

Indication	Step	Required therapy	Requirement for approval	Duration
Eosinophilic esophagitis	1	Proton pump inhibitor or swallowed topical corticosteroid	Inadequate response to either therapy, unless contraindicated or not tolerated	Not specified

Indication	Step	Required therapy	Requirement for approval	Duration
Prurigo nodularis	1	Medium- to super-high-potency topical corticosteroid, topical calcineurin inhibitor, phototherapy, methotrexate, or cyclosporine	Inadequate response to at least one qualifying therapy, or intolerance or a clinical reason to avoid the specified topical/systemic treatment combinations	Not specified

Indication	Step	Required therapy	Requirement for approval	Duration
Chronic spontaneous urticaria	1	Up-dosed second-generation H1 antihistamine	Member remains symptomatic despite guideline-based up-dosing	At least 2 weeks

Indication	Step	Required therapy	Requirement for approval	Duration
Immune checkpoint inhibitor-related pruritus	1	Gabapentinoids for severe grade 3 pruritus	No response to gabapentinoids before authorization	One month

Authorization Duration

Dupixent

DrugDupixent

Authorization period12 months

Period basisPer year; authorization period

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyDupixent (dupilumab) Coverage and Prior Authorization

Policy CodePolicy N/A

Change TypeAdministrative applicability update

Effective DateJul 1, 2026

Last ReviewJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with clinical documentation applicable to the requested indication and evidence that all approval criteria are met.

SourceLink

On This Page

Baseline blood eosinophil count is at least 150 cells per microliter.

Inadequate asthma control despite current treatment at optimized doses with a medium-to-high-dose inhaled corticosteroid and an additional controller (e.g., long-acting beta2-agonist, long-acting muscarinic antagonist, leukotriene modifier, or sustained-release theophylline).

ALL of the following

Inadequate asthma control despite current treatment at optimized doses with a high-dose inhaled corticosteroid, an additional controller, and oral glucocorticoids of at least 5 mg per day of prednisone/prednisolone or equivalent.
Member should have received an inhaled corticosteroid and additional controller for at least the previous 3 months and oral glucocorticoids for most days during the previous 6 months (e.g., 50% of days or 3 steroid bursts in the previous 6 months).

Member will continue to use maintenance asthma treatments (i.e., inhaled corticosteroid and additional controller) in combination with the requested medication.

Meltzer Clinical Score is at least 2 in both nostrils.

Total endoscopic nasal polyp score is at least 5, with a minimum score of 2 for each nostril.

ALL of the following

Member has symptoms of nasal blockage, congestion, or obstruction.
At least ONE additional symptom
- Rhinorrhea (anterior or posterior).
- Reduction or loss of smell.
- Facial pain or pressure.

Member will continue to use a daily intranasal corticosteroid while being treated with the requested medication, unless contraindicated or not tolerated.

Alternatively, authorization of 6 months may be granted for a member 12 years of age or older who has previously received a biologic drug indicated for CRSwNP (e.g., Nucala, Xolair) in the past year.

Member has had an intolerance or clinical reason to avoid either medium- to super-high-potency topical corticosteroid plus topical calcineurin inhibitor, or pharmacologic treatment with methotrexate plus cyclosporine.

Alternatively, authorization of 6 months may be granted for a member 18 years of age or older who has previously received a biologic drug indicated for prurigo nodularis (e.g., Nemluvio) in the past year.

At least two moderate exacerbations in the last year resulting in treatment with systemic glucocorticoids, antibiotics, or both.
One or more severe exacerbations in the last year requiring hospitalization or an emergency medical care visit.

ONE of the following

Member is currently receiving maintenance inhaled triple therapy (inhaled corticosteroid, long-acting muscarinic antagonist, and long-acting beta2-agonist).
Member is currently receiving a long-acting muscarinic antagonist and long-acting beta2-agonist and has a contraindication to inhaled corticosteroids.

Member will continue to use maintenance COPD treatments (e.g., inhaled corticosteroid with long-acting muscarinic antagonist and long-acting beta2-agonist, or long-acting muscarinic antagonist and long-acting beta2-agonist) in combination with the requested medication.

Member has moderate (G2) bullous dermatitis when the diagnosis is bullous pemphigoid.

Member has severe (G3) or life-threatening (G4) bullous dermatitis.

Member achieves or maintains a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms of the condition.

Asthma exacerbation threshold

Corticosteroid exacerbationsAt least 2 exacerbations requiring oral or injectable corticosteroid treatment within the past year

Hospitalization or emergency careAt least 1 exacerbation resulting in hospitalization or an emergency medical care visit within the past year

Alternative uncontrolled-asthma evidencePoor symptom control, including frequent symptoms or reliever use, activity limitation, or night waking

CRSwNP intranasal corticosteroid trial

Minimum trialAt least 4 weeks of intranasal corticosteroid treatment

Disease contextBilateral nasal polyposis with chronic sinusitis symptoms despite treatment

ExceptionTreatment is not required when contraindicated or not tolerated

CRSwNP Meltzer Clinical Score

Minimum scoreMeltzer Clinical Score of 2 or higher

Required distributionScore of at least 2 in both nostrils

Finding typeObjective evidence of bilateral nasal polyposis

CRSwNP endoscopic nasal polyp score

Total scoreTotal endoscopic nasal polyp score of at least 5

Right nostrilMinimum score of 2

Left nostrilMinimum score of 2

Eosinophilic esophagitis biopsy

Biopsy thresholdAt least 15 intraepithelial esophageal eosinophils per high-power field

Diagnostic methodEsophageal biopsy

Diagnostic roleConfirms eosinophilic esophagitis

Prurigo nodularis duration and lesions

Pruritus durationAt least 6 weeks

Lesion thresholdAt least 20 nodular lesions

Additional findingHistory or signs of a repeated itch-scratch cycle

COPD spirometry

Spirometric criterionPost-bronchodilator FEV1/FVC less than 0.7

Diagnostic testSpirometry

Diagnostic purposeConfirms COPD

COPD eosinophil threshold

Minimum countAt least 300 cells per microliter

MeasurementAbsolute blood eosinophil count

TimingBefore initiating therapy with Dupixent

CSU duration

Minimum durationAt least 6 weeks

Qualifying symptomsSpontaneous wheals, angioedema, or both

Required evaluationEvaluation for other causes of wheals and/or angioedema

Immune checkpoint toxicity gabapentinoid trial

Required prior therapyGabapentinoids for severe grade 3 pruritus

Trial durationOne month

Response requirementNo response to gabapentinoids

Eosinophilic esophagitis minimum age

Minimum ageAt least 1 year

Applicable conditionEosinophilic esophagitis

Authorization stageReauthorization eligibility

Eosinophilic esophagitis minimum weight

Minimum weightAt least 15 kg

Applicable conditionEosinophilic esophagitis

Authorization stageReauthorization eligibility

Asthma reauthorization minimum age

Minimum ageAt least 6 years

Applicable conditionAsthma

Authorization period12 months

CRSwNP and chronic spontaneous urticaria reauthorization minimum age

Minimum ageAt least 12 years

CRSwNPChronic rhinosinusitis with nasal polyposis

CSUChronic spontaneous urticaria

Prurigo nodularis and COPD reauthorization minimum age

Minimum ageAt least 18 years

Prurigo nodularisAdults 18 years of age or older

COPDMembers 18 years of age or older

Pulmonologist: asthma or COPD; otolaryngologist: CRSwNP; gastroenterologist: EoE.

Hematologist or oncologist: immune checkpoint inhibitor-related toxicity.

Note

Initial Authorization Duration

Initial authorization periods are indication-specific. Requests must meet the applicable age, diagnosis, severity, treatment-history, laboratory, and continuation-of-therapy requirements.

Atopic dermatitis: 4 months; asthma: 6 months; CRSwNP: 6 months; EoE: 6 months.
Prurigo nodularis: 6 months; COPD: 12 months; CSU: 6 months; immune checkpoint inhibitor-related toxicity: 12 months.
Prior biologic use within the applicable lookback period may support authorization for several indications, but the member must still satisfy the applicable policy requirements.

Prior Authorization

Prior Authorization Required

Prior authorization is required before Dupixent is covered. Submit the request using HMSA's medical specialty drug prior authorization process.

Refer to the HMSA medical specialty drug policy website for the required fax form.

Step Therapy

Atopic Dermatitis Topical Therapy Step

For atopic dermatitis, document the required prior topical therapy step unless those therapies are clinically inadvisable.

Disease must affect at least 10% body surface area or a crucial body area such as the hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas.
Document inadequate response within the past 180 days to two of the following: high- or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, or topical PDE-4 inhibitor.
Alternatively, document why the relevant high-potency or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, and topical PDE-4 inhibitor are not advisable, such as contraindication, prior intolerance, or age-inappropriate potency.

Step Therapy

Asthma Controller Therapy Step

For moderate-to-severe asthma, document uncontrolled disease and optimized controller therapy before requesting Dupixent.

Document at least one qualifying event in the past year: two or more exacerbations requiring oral or injectable corticosteroids, an exacerbation requiring hospitalization or emergency care, or poor symptom control.
One pathway requires baseline eosinophils of at least 150 cells/µL plus inadequate control despite optimized medium-to-high-dose inhaled corticosteroid and an additional controller.
The alternative pathway requires optimized high-dose inhaled corticosteroid, an additional controller, and oral glucocorticoids of at least 5 mg/day prednisone or equivalent; inhaled corticosteroid and controller therapy should be used for at least 3 months and oral glucocorticoids for most days during the prior 6 months.
Document that maintenance inhaled corticosteroid and additional controller therapy will continue with Dupixent.

Step Therapy

CRSwNP Treatment Step

For CRSwNP, document persistent disease despite intranasal corticosteroid therapy and the required prior treatment history.

Document bilateral nasal polyposis and chronic sinusitis symptoms despite intranasal corticosteroid treatment for at least 4 weeks, unless contraindicated or not tolerated.
Document prior sinonasal surgery or ineffective systemic corticosteroid treatment within the last 2 years, unless contraindicated or not tolerated.
Document that daily intranasal corticosteroid therapy will continue with Dupixent unless contraindicated or not tolerated.

Step Therapy

Eosinophilic Esophagitis Treatment Step

For EoE, document inadequate response to a proton pump inhibitor or swallowed topical corticosteroid therapy.

Qualifying swallowed topical corticosteroids include budesonide or fluticasone powder or suspension for inhalation.
Document contraindication or intolerance when the required therapy is not advisable.

Step Therapy

Prurigo Nodularis Treatment Step

For PN, document the qualifying itch, lesion burden, and prior-treatment response or treatment-avoidance rationale.

Member must have pruritus lasting at least 6 weeks, a repeated itch-scratch cycle, and at least 20 nodular lesions.
Document inadequate response to at least one medium- to super-high-potency topical corticosteroid, topical calcineurin inhibitor, phototherapy, methotrexate, or cyclosporine.
Alternatively, document intolerance or a clinical reason to avoid both topical corticosteroid and topical calcineurin inhibitor therapy, or both methotrexate and cyclosporine.

Step Therapy

CSU Antihistamine Step

For CSU, document persistent symptoms despite guideline-directed up-dosing of a second-generation H1 antihistamine.

Treatment must have been up-dosed in accordance with EAACI/GA²LEN/EuroGuiDerm/APAAACI guidelines for at least 2 weeks.
Examples include cetirizine, fexofenadine, levocetirizine, or loratadine.

Step Therapy

Immune Checkpoint Toxicity Step

For severe grade 3 immune checkpoint inhibitor-related pruritus, document no response to a gabapentinoid trial in one month before requesting Dupixent.

The policy also addresses Dupixent as additional therapy for qualifying bullous pemphigoid or severe/life-threatening bullous dermatitis.

Documentation Required

Atopic Dermatitis Documentation

For atopic dermatitis, provide documentation sufficient to establish disease extent, prior treatment, and treatment response.

Document affected areas and body surface area when applicable.
List previous medications, including topical calcineurin inhibitors, topical corticosteroids, topical JAK inhibitors, topical PDE-4 inhibitors, biologics, or targeted synthetic drugs, with dosage, duration, and response.
For continuation, document positive clinical response.

Documentation Required

Asthma Documentation

For asthma, document the pretreatment blood eosinophil count when applicable and the complete prior medication history.

List each prior medication, dose, frequency, and duration.
For continuation, document improvement in asthma control.

Documentation Required

CRSwNP Documentation

For CRSwNP, document objective nasal disease findings and the relevant treatment history.

Provide nasal endoscopy, anterior rhinoscopy, or CT details, including polyp location and size when available.
Include the Meltzer Clinical Score or endoscopic nasal polyp score when applicable.
Document prior medications with drug, dose, frequency, and duration, or the clinical reason therapy was not advisable.
For continuation, document positive clinical response.

Documentation Required

Eosinophilic Esophagitis Documentation

For EoE, document biopsy-confirmed disease and prior treatment history.

Provide endoscopic biopsy details, including the intraepithelial esophageal eosinophil count.
Document previous medications tried or the clinical reason therapy was not advisable.
For continuation, document positive clinical response.

Documentation Required

Prurigo Nodularis Documentation

For PN, document the characteristic symptoms and lesions, previous therapies, and response.

Document pruritus and nodular lesions when applicable.
List prior therapies and response, or the clinical reason therapy was not advisable.
For continuation, document positive clinical response.

Documentation Required

COPD Documentation

For COPD, document objective diagnosis, symptoms, eosinophil count, treatment history, and recent exacerbations.

Provide spirometry confirming post-bronchodilation FEV1/FVC less than 0.7 and document classic COPD symptoms.
Document prior medications and response, or the clinical reason therapy was not advisable.
Provide the absolute blood eosinophil count before initiating Dupixent and document moderate or severe exacerbations within the last year.
For continuation, document positive clinical response.

Documentation Required

CSU Documentation

For CSU, document prior medication use and response for initial requests and continued response for reauthorization.

Provide chart notes, medical records, or claims history showing previous medications tried and response to therapy.
Document evaluation for other causes of wheals or angioedema when relevant.
For continuation, document positive response to therapy.

Denial Risk

Uncovered Indication or Unmet Criteria

Dupixent is not covered when the requested use is not an FDA-approved or compendial indication, or when the applicable approval criteria are not met.

Submit documentation supporting the specific requested indication.
Denial risk increases when required diagnosis, age, severity, prior-treatment, laboratory, or response criteria are absent or unmet.

Denial Risk

Limitations of Use

Dupixent is not indicated for relief of acute bronchospasm or status asthmaticus, or for treatment of forms of urticaria other than CSU.

Do not request coverage for acute bronchospasm, status asthmaticus, or non-CSU urticaria.

Denial Risk

Initial Criteria Required Without Prior Authorization

All members, including new HMSA members and members currently receiving Dupixent without prior authorization, must satisfy the initial approval criteria.

A prior authorization history from another payer or treatment without prior authorization does not replace the initial-criteria review.

Denial Risk

Indication-Specific Criteria

Requests may be denied when indication-specific age, severity, treatment, laboratory, diagnostic, or maintenance criteria are not documented or are unmet.

Verify age and, for EoE, minimum weight of 15 kg.
Verify required disease severity, objective diagnostic findings, eosinophil thresholds, exacerbation history, prior therapies, and ongoing maintenance therapy for the requested indication.

Denial Risk

Insufficient Response at Reauthorization

Reauthorization requires prior HMSA/CVS authorization and documented positive clinical response or improvement during therapy; the applicable age, weight, and maintenance requirements must continue to be met.

Atopic dermatitis: low disease activity or improvement in redness, itching, oozing, or crusting.
Asthma: reduced symptom or exacerbation frequency/severity or reduced daily maintenance oral corticosteroid dose, with maintenance inhaled corticosteroid and additional controller continued.
CRSwNP: improvement in nasal congestion, polyp size, smell, rhinorrhea, inflammation, hyposmia, facial pressure/pain, or corticosteroid use, with daily intranasal corticosteroid continued unless contraindicated or not tolerated.
EoE and immune checkpoint inhibitor-related toxicity require documented achieved or maintained positive response; submit the applicable continuation records.

Denial Risk

Unqualified Prescriber

Requests may be denied when the prescriber does not meet the policy's specialist qualification requirement or lacks the required specialist consultation.

Confirm that the prescribing or consulting specialist is appropriate for the requested indication.

Denial Risk

Concomitant Therapy Restriction

Dupixent must not be used concomitantly with another biologic drug or targeted synthetic drug for the same indication.

Document discontinuation or nonuse of another same-indication biologic or targeted synthetic drug before approval or continuation.

Denial Risk

Failure to Meet Reauthorization Criteria

Reauthorization may be denied when prior HMSA/CVS authorization, applicable age or weight requirements, documented positive response, or required maintenance therapy is not established.

Submit current clinical notes showing that the member achieved or maintained benefit from Dupixent.
For asthma and CRSwNP, document continuation of required controller or intranasal corticosteroid therapy unless contraindicated or not tolerated.
For EoE, verify age and minimum weight requirements and document ongoing improvement in symptoms.
For immune checkpoint inhibitor-related toxicity, document prior HMSA/CVS authorization and maintained response.

Eosinophilic esophagitis

DefinitionEosinophilic esophagitis confirmed by biopsy

Biopsy findingAt least 15 intraepithelial esophageal eosinophils per high-power field

Clinical contextSymptoms of esophageal dysfunction may include dysphagia, food impaction, vomiting, abdominal pain, food refusal, or failure to thrive

COPD diagnostic criterion

DefinitionCOPD confirmed by spirometry

MeasurementForced expiratory volume in one second divided by forced vital capacity (FEV1/FVC)

Required resultLess than 0.7 after bronchodilation

Chronic spontaneous urticaria

SymptomsSpontaneous wheals, angioedema, or both

DurationAt least 6 weeks

Exclusion assessmentOther causes of wheals or angioedema have been evaluated

ICS

AbbreviationICS

MeaningInhaled corticosteroid

Use in policyA maintenance treatment used with Dupixent for asthma or COPD

LAMA

AbbreviationLAMA

MeaningLong-acting muscarinic antagonist

Use in policyA maintenance COPD treatment

LABA

AbbreviationLABA

MeaningLong-acting beta agonist

Use in policyAn additional controller or maintenance COPD treatment

UAS7

AbbreviationUAS7

MeaningWeekly urticaria activity score

Reauthorization useA decrease in UAS7 may demonstrate positive clinical response

G2/G3/G4

G2Moderate immune checkpoint inhibitor-related toxicity

G3Severe immune checkpoint inhibitor-related toxicity

G4Life-threatening immune checkpoint inhibitor-related toxicity

Member is at least 6 years old, has uncontrolled moderate-to-severe asthma, meets the qualifying eosinophilic or oral-glucocorticoid treatment pathway, and will continue inhaled corticosteroid plus an additional controller.Age >= 6 years; authorization period 6 months

Chronic rhinosinusitis with nasal polyps — 6-month initial authorization criteria

Authorization of 6 months may be granted when all criteria are met.

Member is at least 12 years old and has bilateral CRSwNP with persistent symptoms despite required intranasal corticosteroid treatment, qualifying prior treatment, objective polyp burden, required symptoms, and continued daily intranasal corticosteroid unless contraindicated or not tolerated.Age >= 12 years; authorization period 6 months

Eosinophilic esophagitis — 6-month initial authorization criteria

Authorization of 6 months may be granted when all criteria are met.

Member is at least 1 year old, weighs at least 15 kg, has symptomatic biopsy-confirmed eosinophilic esophagitis, and had an inadequate response to a proton pump inhibitor or swallowed topical corticosteroid unless contraindicated or not tolerated.Age >= 1 year; weight >= 15 kg; authorization period 6 months

Prurigo nodularis — 6-month initial authorization criteria

Authorization of 6 months may be granted when all criteria are met.

Member is at least 18 years old, has pruritus for at least 6 weeks, a repeated itch-scratch cycle, at least 20 nodular lesions, and qualifying prior-treatment failure or treatment avoidance.Age >= 18 years; pruritus >= 6 weeks; >= 20 lesions; authorization period 6 months

Chronic obstructive pulmonary disease — 12-month initial authorization criteria

Authorization of 12 months may be granted when all criteria are met.

Member is at least 18 years old and has spirometry-confirmed COPD, classic symptoms, eosinophils of at least 300 cells per microliter, qualifying exacerbations, qualifying maintenance inhaler therapy, and continued COPD maintenance treatment.Age >= 18 years; FEV1/FVC < 0.7; eosinophils >= 300 cells/microliter; authorization period 12 months

Chronic spontaneous urticaria — 6-month initial authorization criteria

Authorization of 6 months may be granted when all criteria are met.

Member is at least 12 years old, remains symptomatic despite up-dosed second-generation H1 antihistamine for at least 2 weeks, has been evaluated for other causes, and has spontaneous wheals, angioedema, or both for at least 6 weeks.Age >= 12 years; authorization period 6 months

Immune checkpoint inhibitor-related toxicity — 12-month initial authorization criteria

Authorization of 12 months may be granted for the applicable toxicity pathway.

ANY of the following

Member has severe grade 3 pruritus with no response to gabapentinoids in one month.G3; one month
Member has qualifying bullous pemphigoid or bullous dermatitis requiring additional therapy.G2 bullous pemphigoid, or G3/G4 bullous dermatitis

Member will continue inhaled corticosteroid and an additional controller with Dupixent.

CRSwNP reauthorization — 12-month continuation criteria

Authorization of 12 months may be granted when both criteria are met.

ALL of the following

Member is at least 12 years old, was previously authorized by HMSA/CVS, and has achieved or maintained positive clinical response with Dupixent.Age >= 12 years
Member will continue a daily intranasal corticosteroid unless contraindicated or not tolerated.

Asthma — continued maintenance therapy requirement

Continued maintenance therapy is required for asthma reauthorization.

Member will continue to use an inhaled corticosteroid and an additional controller in combination with Dupixent.

Chronic rhinosinusitis with nasal polyposis — continued intranasal corticosteroid requirement

Continued intranasal corticosteroid therapy is required unless contraindicated or not tolerated.

Member will continue to use a daily intranasal corticosteroid while being treated with Dupixent.

Chronic obstructive pulmonary disease — continued maintenance therapy requirement

Continued maintenance therapy is required for COPD reauthorization.

Member will continue maintenance COPD treatment, such as ICS with LAMA and LABA or LAMA and LABA, in combination with Dupixent.