CurrentHawaii Medical Service Association (HMSA)Policy N/A

Adbry (tralokinumab-ldrm) Coverage Criteria

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This policy governs HMSA commercial coverage and prior authorization for Adbry in members aged 12 years and older with moderate-to-severe atopic dermatitis. It defines clinical criteria, documentation, prescriber qualifications, continuation requirements, and authorization durations.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyAdbry (tralokinumab-ldrm) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative line-of-business update

Effective DateJul 1, 2026

Last ReviewMar 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Adbry and refer to the HMSA medical policy website for the fax form.

SourceLink

POLICY UPDATE CHANGES

The QUEST line of business was removed effective 07/01/2026.

12+Minimum member age

≥10% BSABody-surface-area threshold

180 daysPrior-treatment lookback

4 monthsInitial authorization

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CurrentHawaii Medical Service Association (HMSA)Policy N/A

Adbry (tralokinumab-ldrm) Coverage Criteria

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)

PolicyAdbry (tralokinumab-ldrm) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative line-of-business update

Effective DateJul 1, 2026

Last ReviewMar 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Adbry and refer to the HMSA medical policy website for the fax form.

SourceLink

POLICY UPDATE CHANGES

The QUEST line of business was removed effective 07/01/2026.

12+Minimum member age

≥10% BSABody-surface-area threshold

180 daysPrior-treatment lookback

4 monthsInitial authorization

12 monthsReauthorization

ProhibitedConcurrent same-indication therapy

Coverage Criteria

Initial Therapy: Prior Biologic or Targeted Synthetic Drug

Covered for initial approval when both of the following are met:

Prior advanced therapy pathway

Eligibility: Member is 12 years of age or older and has previously received a biologic or targeted synthetic drug indicated for moderate-to-severe atopic dermatitis within the past 180 days.Age ≥12 years; prior therapy within 180 days
Examples include Dupixent, Cibinqo, and Rinvoq.

Initial Therapy: Disease Severity and Topical Therapy

Covered for initial approval when all of the following are met:

Disease severity and topical-treatment pathway

Disease severity
- Affected body surface is greater than or equal to 10% body surface area.≥10% body surface area
- A crucial body area is affected, including the hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas.
  Crucial body-area involvement may satisfy the disease-severity requirement without meeting the body-surface-area threshold.
Topical-treatment qualification
- Member has had an inadequate treatment response to two qualifying topical therapies within the past 180 days.Two therapies within the past 180 days
  Qualifying therapies are a high-potency or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, or topical PDE-4 inhibitor.
- Use of a high-potency or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, and topical PDE-4 inhibitor is not advisable for the member.All four listed topical therapy classes not advisable
  Examples include contraindications, prior intolerances, or potency not appropriate for the member’s age.

Continuation Therapy: No Previous Authorization

Members without previous HMSA/CVS authorization must meet the initial-approval criteria.

No previous authorization: All members, including new members and members currently receiving Adbry without prior authorization, must meet the criteria for initial approval in section D.Initial-approval criteria required

Applies when there is no previous HMSA/CVS authorization or precertification.

Continuation Therapy: Reauthorization

Reauthorization may be granted when all of the following are met:

Reauthorization response

Member is 12 years of age or older and was previously authorized by HMSA/CVS.Age ≥12 years; previous HMSA/CVS authorization
Member has achieved or maintained a positive clinical response since starting Adbry therapy.
Positive response is evidenced by low disease activity, such as clear or almost clear skin, or improvement in signs and symptoms including redness, itching, or oozing/crusting.

Adbry cannot be used concomitantly with another biologic drug or targeted synthetic drug for the same indication.

Key Coverage Thresholds

Affected body surface area

Threshold≥10% body surface area

ExceptionCoverage may also qualify when crucial body areas are affected

Crucial body areasHands, feet, face, neck, scalp, genitals/groin, and intertriginous areas

Prior treatment lookback

Lookback periodPast 180 days

Applies toQualifying prior biologic or targeted synthetic therapy, or inadequate response to two qualifying topical therapies

Prior advanced-therapy examples

Provider Requirements and Decision Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for Adbry. Use the HMSA medical policy website fax form to submit the request.

Step Therapy

Prior Biologic or Targeted Synthetic Therapy

An initial 4-month authorization may be available for members 12 years of age or older who received a biologic or targeted synthetic drug indicated for moderate-to-severe atopic dermatitis within the past 180 days.

Qualifying examples include Dupixent, Cibinqo, and Rinvoq.
Document the prior therapy and applicable treatment history in the request.

Step Therapy

Topical Therapy Trial or Clinical Unsuitability

Policy Background

Adbry (tralokinumab-ldrm) is covered for patients 12 years of age and older with moderate-to-severe atopic dermatitis that is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Adbry may be used with or without topical corticosteroids. Coverage considers disease extent or involvement of crucial body areas, prior topical or advanced-therapy experience, and clinical response during continuation therapy.

Initial Approval

Authorization of 4 months may be granted through either of the following pathways:

Initial approval pathways

Prior advanced-therapy pathway
- Member is 12 years of age or older and has previously received a biologic or targeted synthetic drug indicated for moderate-to-severe atopic dermatitis within the past 180 days.Age ≥12 years; prior therapy within 180 days
  Examples include Dupixent, Cibinqo, and Rinvoq.
Disease-severity and topical-treatment pathway
- Member is 12 years of age or older.Age ≥12 years

Continuation and Reauthorization

No Previous Authorization

Members without previous HMSA/CVS authorization must meet the initial-approval criteria.

Applies when there is no previous HMSA/CVS authorization or precertification.

Reauthorization

Reauthorization may be granted for 12 months when all of the following are met:

Positive clinical response

Member is 12 years of age or older and was previously authorized by HMSA/CVS.Age ≥12 years; previous HMSA/CVS authorization

Step Therapy Pathways

Step	Requirement	Qualifying details
{"text":"1","status":""},{"text":"Trial of two qualifying topical therapies, or documentation that all four listed topical therapy classes are not advisable.","status":"covered"},{"text":"For the trial pathway, the member must have had an inadequate treatment response to two therapies within the past 180 days. Qualifying classes: high- or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, and topical PDE-4 inhibitor. The not-advisable pathway applies when use of all four classes is not advisable, such as because of contraindications, prior intolerances, or potency inappropriate for the member’s age.","status":""}

Step	Requirement	Qualifying details
{"text":"2","status":""},{"text":"Prior receipt of a biologic or targeted synthetic drug indicated for moderate-to-severe atopic dermatitis may satisfy the alternative initial-approval pathway.","status":"covered"},{"text":"The therapy must have been received within the past 180 days, and the member must be 12 years of age or older. Examples include Dupixent, Cibinqo, and Rinvoq.","status":""}

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyAdbry (tralokinumab-ldrm) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative line-of-business update

Effective DateJul 1, 2026

Last ReviewMar 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Adbry and refer to the HMSA medical policy website for the fax form.

SourceLink

On This Page

Dupixent, Cibinqo, and Rinvoq

Minimum age

Minimum age12 years

Initial approvalMember must be 12 years of age or older

Covered conditionModerate-to-severe atopic dermatitis

For the non-advanced-therapy pathway, document an inadequate response to two qualifying topical therapies within the past 180 days, or document why the qualifying topical therapies are clinically unsuitable.

Qualifying therapies include a high- or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, and topical PDE-4 inhibitor.
Clinical unsuitability may include contraindications, prior intolerance, or potency not appropriate for the member's age.

Documentation Required

Initial Clinical Documentation

Initial requests must include chart notes or medical records documenting the affected areas and body surface area, where applicable, along with prior medications tried and the dosage, duration, and response to each therapy.

Documentation may include claims history for previous therapies.
Include clinical rationale when a therapy was not advisable.

Documentation Required

Continuation Documentation

Continuation requests must include chart notes or medical records supporting a positive clinical response to Adbry.

Document low disease activity, such as clear or almost clear skin, or improvement in signs and symptoms including redness, itching, or oozing/crusting.

Denial Risk

Initial Criteria Not Met

The initial request may be denied when the member is younger than 12, does not have moderate-to-severe atopic dermatitis meeting the required severity threshold, lacks the required prior treatment history, or does not meet the applicable initial-approval pathway.

The affected body surface must be at least 10% or involve a crucial area such as the hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas.
For the topical pathway, the member must have an inadequate response to two qualifying therapies within the past 180 days, or all specified topical options must be clinically unsuitable.
Authorization under the prior biologic or targeted synthetic pathway requires qualifying treatment within the past 180 days.

Denial Risk

Continuation Requirements Not Met

Members without a previous HMSA/CVS authorization—including new members and members already receiving Adbry without prior authorization—must meet the initial-approval criteria. Reauthorization may be denied unless the member is at least 12, was previously authorized by HMSA/CVS, and achieved or maintains a positive clinical response since starting Adbry.

Reauthorization is for 12 months when requirements are met.
Positive response must be evidenced by low disease activity or improvement in atopic dermatitis signs and symptoms.

Denial Risk

Prohibited Concomitant Therapy

Adbry cannot be used concomitantly with another biologic drug or targeted synthetic drug for the same indication. Requests involving prohibited concomitant therapy may be denied.

Note

Prescriber Specialty Requirement

Adbry must be prescribed by, or prescribed in consultation with, a dermatologist or allergist/immunologist.

Affected body surface is greater than or equal to 10% body surface area.≥10% body surface area
A crucial body area is affected, including the hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas.

Topical-treatment qualification

Member has had an inadequate treatment response to two qualifying topical therapies within the past 180 days.Two therapies within the past 180 days
Qualifying therapies are a high-potency or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, or topical PDE-4 inhibitor.
Use of a high-potency or super-high-potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, and topical PDE-4 inhibitor is not advisable for the member.All four listed topical therapy classes not advisable
Examples include contraindications, prior intolerances, or potency not appropriate for the member’s age.

Member has achieved or maintained a positive clinical response since starting Adbry therapy.12-month reauthorization

Positive response is evidenced by low disease activity, such as clear or almost clear skin, or improvement in signs and symptoms including redness, itching, or oozing/crusting.