CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization Request Form — Dupixent (dupilumab)

This HMSA/CVS Caremark prior authorization form collects clinical and administrative information to determine coverage for Dupixent (dupilumab) across multiple indications and is intended for prescribing providers submitting PA requests to CVS Caremark.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request Form — Dupixent (dupilumab)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization to CVS Caremark (fax 1-866-237-5512) with the completed indication-specific questionnaire and required supporting chart notes/records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multi-indicationIndications

requiredPrior auth

fax submissionFax submission

requiredDocumentation

>=300Eosinophil cutoff

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Coverage Criteria by Indication

Atopic Dermatitis

Covered when ALL of the following are met for new starts or continuation:

Age and prescriber: Member is >=6 months of age and medication is prescribed by or in consultation with a dermatologist or allergist/immunologist

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Continuation response: For continuation: patient has achieved or maintained a positive clinical response (clear or almost clear skin or improvement in signs/symptoms) since starting therapy and supporting chart notes are attached

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New start prior therapy: For new starts: patient has NOT received another biologic or systemic targeted synthetic for atopic dermatitis in the past 180 days (excluding samples/PAP); AND patient has >=10% BSA affected or <10% with crucial body areas affected; AND patient had inadequate response to TWO of the specified topical agents within the past 180 days (high‑potency/super‑high potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, topical PDE‑4 inhibitor) with documentation of the two agents, dosage, duration, and responseBSA >=10% option present

chunks 5-6

Asthma

Covered when ALL of the applicable criteria below are met:

Age and prescriber: Patient is >=6 years of age and request is prescribed by or in consultation with an allergist/immunologist or pulmonologist

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Continuation response: For continuation: documentation of improved asthma control on Dupixent (reduction in frequency/severity of symptoms or exacerbations, or reduction in maintenance oral corticosteroid dose) is required; and patient will continue maintenance asthma treatments in combination with Dupixent

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New start severity and prior therapy: For new starts: patient has not received a biologic for asthma in the past year (excluding samples/PAP); patient demonstrates uncontrolled asthma shown by either: >=2 exacerbations requiring oral/injectable corticosteroids in the past year, OR >=1 exacerbation resulting in hospitalization/ED visit in the past year, OR poor symptom control; baseline pre‑treatment blood eosinophil count must be provided (>=150 cells/µL branch guides pathway); and documentation of prior inadequate control despite optimized medium‑to‑high‑dose ICS plus an additional controller (or high‑dose ICS + controller + oral glucocorticoids when applicable) with durations as requested

Chronic rhinosinusitis with nasal polyposis

Covered when ALL of the following applicable criteria are met:

Age and prescriber: Patient is >=12 years of age and medication is prescribed by or in consultation with an allergist/immunologist or otolaryngologist

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Continuation response: For continuation: documentation of positive clinical response (improvement in nasal congestion, polyp size, smell, rhinorrhea, sinonasal inflammation, or reduced corticosteroid use) and continued use of daily intranasal corticosteroid unless contraindicated

chunks 11-12

New start prerequisites: For new starts: patient has not received a biologic for CRSwNP in the past year (excluding samples/PAP); patient has bilateral nasal polyposis with chronic sinusitis symptoms; trial of intranasal corticosteroid for >=4 weeks unless contraindicated; and either prior sino‑nasal surgery OR inadequate response to systemic corticosteroids within last 2 years OR contraindication to systemic corticosteroids; objective evidence of polyps on endoscopy/CT or meeting Meltzer/NPS thresholds (total endoscopic NPS >=5 with minimum score of 2 per nostril or Meltzer >=2) must be provided

Eosinophilic Esophagitis

Covered when ALL of the following are met for EoE:

Age/weight and prescriber: Patient is >=1 year of age, weighs >=15 kg, and Dupixent is prescribed by or in consultation with a gastroenterologist or an allergist/immunologist

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Diagnosis confirmation: Diagnosis confirmed by esophageal biopsy showing >=15 intraepithelial esophageal eosinophils per high power field (attach endoscopic biopsy documentation)>=15 eos/hpf

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Prior therapy: Documented inadequate response to a proton pump inhibitor and to swallowed topical corticosteroids (e.g., budesonide, fluticasone) unless these therapies are contraindicated or not tolerated (attach supporting chart notes)

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Prurigo Nodularis

Covered when ALL of the following are met for prurigo nodularis (new starts) or continuation:

Adult and prescriber: Patient is an adult and Dupixent is prescribed by or in consultation with a dermatologist or allergist/immunologist

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Continuation response: For continuation: evidence of positive clinical response (reduced pruritus intensity or improvement in extent/severity of nodular lesions) with supporting chart notes attached

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New start prerequisites: For new starts: patient has not received a biologic for prurigo nodularis in the past year; pruritus lasting >=6 weeks and history/signs of repeated itch‑scratch cycle; minimum of 20 nodular lesions; inadequate response to medium to super‑high potency topical corticosteroid and topical calcineurin inhibitor, phototherapy, and systemic agents (methotrexate or cyclosporine) as applicable, or documented contraindication/intolerance to these therapies with reasons attached>=20 nodules

Immune checkpoint inhibitor-related toxicity

Covered when the following are met for ICI-related dermatologic toxicity:

Prescriber and indication: Dupixent is prescribed by or in consultation with a dermatologist, hematologist, or oncologist; indication is selected by grade (e.g., severe G3 pruritis; moderate‑severe‑life‑threatening G2–G4 bullous dermatitis) and documented

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Continuation/new start: For continuation: documentation of clinical response is required (attach chart notes); for new starts: ensure prior failure of gabapentinoids for severe pruritis when applicable and that Dupixent will be used as additional therapy for moderate to life‑threatening bullous dermatitis as indicated

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COPD (partial)

COPD criteria referenced in form (partial content in this excerpt):

Prescriber and age: Requested drug is prescribed by or in consultation with a pulmonologist or allergist/immunologist and patient adult status is confirmed

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Immune checkpoint inhibitor–related toxicity continuation

Covered when the following indication-specific continuation criteria are satisfied:

ICI-toxicity_continuation: 1) Prescriber is or has consulted a dermatologist, hematologist, or oncologist; 2) This is a continuation request; 3) Indication selected is one of the listed grades (e.g., severe pruritis G3, moderate/severe/life‑threatening bullous dermatitis G2–G4) or other; 4) If bullous dermatitis, documentation whether patient has bullous pemphigoid; 5) For continuation, patient has achieved or maintained a positive clinical response as evidenced by improvement in signs and symptoms since starting the drug (attach supporting notes)

Question flow items #300-304

COPD continuation and initiation criteria

Covered when ALL required COPD documentation and criteria are provided:

COPD_confirmation_and_response: 1) Prescriber is or has consulted a pulmonologist or allergist/immunologist; 2) Patient is an adult; 3) For continuation, evidence patient is receiving the drug (not only samples/PAP) and has achieved or maintained positive clinical response or disease stabilization (attach documentation); 4) Document prior biologic use in past year if present (attach records); 5) Diagnosis confirmed by spirometry (FEV1/FVC < 0.7 post‑bronchodilation) OR classic COPD signs/symptoms (attach notes); 6) Current maintenance inhaled therapy status (ICS/LAMA/LABA or LAMA+LABA) and any contraindication to ICS documented; 7) Absolute blood eosinophil count prior to initiating therapy provided (>=300 cells/µL); 8) Exacerbation history meets criteria (>=1 severe exacerbation requiring hospitalization/ED in past year OR >=2 moderate exacerbations treated with systemic steroids/antibiotics in past year)eosinophils >=300 cells/µL

Question flow items #350-365

Chronic spontaneous urticaria criteria

Covered when ALL CSU-specific criteria are met:

CSU_initial_and_continuation: 1) Medication prescribed by or in consultation with an allergist, immunologist, or dermatologist; 2) Patient is >=12 years of age; 3) For continuation, documentation patient is not only receiving samples/PAP and has experienced a positive response since initiation (attach documentation); 4) Document prior biologic use for CSU in past year if applicable; 5) Duration of spontaneous wheals/angioedema considered (>=6 weeks typical for CSU); 6) Patient remains symptomatic despite up‑dosing a second‑generation H1 antihistamine for at least 2 weeks per guideline recommendations; 7) Evaluation for alternative causes of wheals/angioedema has been completed and documentedage >=12

Question flow items #400-408

If the provider selects Other for diagnosis on the PA form, the questionnaire flow immediately indicates No Further Questions. The excerpt provides no additional approval pathway or indication-specific criteria when "Other" is chosen; therefore the form stops collecting further clinical items for that selection.

Several checkbox options in the form are labeled to trigger an immediate stop in the questionnaire with No Further Questions. Examples include specific clinical reasons to avoid therapies (e.g., hypersensitivity, pregnancy, significant comorbidity) and certain continuation-response answers (e.g., select responses under CSU or PN indicating prior biologic use or intolerances). When one of these boxes is selected the form directs the user that no further questions are required in the excerpted flow.

Use of the requested drug may be considered not medically necessary when required prior therapies or trials are not documented. The form requires documentation of prior biologic/systemic targeted synthetic use (e.g., for AD within the past 180 days or for PN within the past year) and specific prior topical, phototherapy, or systemic agents as applicable; failure to show the required trials, durations, or objective severity measures (e.g., BSA, nodules) without documented contraindication may result in a determination of not medically necessary.

Requested Diagnosis & Clinical Thresholds

Requested diagnosis codingmixed

ICD-10

Field asking 'What is the ICD-10 code?' (no specific codes listed)

Asthma baseline eosinophil threshold

Eosinophil count for asthma (baseline)>= 150 cells per microliter

ContextBaseline blood eosinophil count is requested prior to initiating therapy to guide pathway for asthma new starts

ActionAttach chart note or lab result showing absolute blood eosinophil count prior to starting therapy

CRSwNP NPS / Meltzer thresholds

CRSwNP endoscopic nasal polyps score (NPS)Total endoscopic NPS >= 5 with minimum score of 2 per nostril

Alternate scoreMeltzer Clinical Score >= 2 in both nostrils may also be used as documented in the form

ActionAttach chart notes or medical record documenting endoscopic NPS or Meltzer score

Eosinophilic Esophagitis diagnostic threshold

EoE biopsy threshold>= 15 intraepithelial esophageal eosinophils per high power field

Documentation requiredAttach supporting chart notes or medical record documentation of endoscopic biopsy with eosinophil count

Prior therapy requirementDocument inadequate response to PPI and swallowed topical corticosteroids unless contraindicated

Atopic dermatitis body surface area (BSA)

Atopic dermatitis BSA options>= 10% of body surface area

Atopic dermatitis BSA alternative< 10% of BSA — form queries whether crucial body areas are affected (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

ActionAttach supporting chart note(s) documenting affected areas and BSA

Absolute blood eosinophil count threshold

Absolute blood eosinophil count>= 300 cells per microliter

When collectedIndicate eosinophil count prior to initiating therapy (before significant oral steroid use) and attach documentation

Action for COPD pathwayCounts >=300 cells/µL guide continuation/initial therapy pathway; attach chart/lab evidence

Submission, Documentation, and Prior Authorization Requirements

Prior Authorization

Prior Authorization Submission Required

Prior authorization requests must be submitted to CVS Caremark. Fax the completed prior authorization form and all required supporting documentation to CVS Caremark toll-free at 1-866-237-5512. For questions about prior authorization determinations contact CVS Caremark at 1-808-254-4414. For eligibility, copay, or medication delivery questions contact CaremarkConnect® Specialty Customer Care at 1-800-237-2767.

Submit PA to CVS Caremark: fax 1-866-237-5512
PA questions: 1-808-254-4414
Eligibility/copay/delivery: CaremarkConnect 1-800-237-2767

Documentation Required

Complete Indication-Specific Questionnaire and Attach Documentation

Complete the indication-specific questionnaire on the HMSACOM prior authorization form and attach supporting chart notes or medical record documentation as requested by the question set. Attach documentation showing diagnosis details, affected body surface area or symptom descriptions, prior therapies tried (drug name, dosage form, strength, dose, duration), responses to therapy, and any relevant test results (e.g., spirometry, eosinophil count, biopsy, endoscopy) where prompted.

Complete all applicable questionnaire items for the selected diagnosis
Attach chart notes/medical records documenting diagnosis, prior therapies, doses, duration, and response
Attach specific test results or procedure reports when requested (e.g., spirometry, biopsy, endoscopy)

Step Therapy

Prior Biologic or Targeted Synthetic Drug Use — Document and Attach Records

For new-start requests, document whether the patient has received or is currently receiving a biologic or targeted synthetic agent within the specified prior timeframe for the indication. Examples include prior biologics for atopic dermatitis (e.g., Adbry, Ebglyss, Nemluvio) or targeted synthetics (e.g., Cibinqo, Rinvoq) within the past 180 days, or prior biologics for asthma, COPD, CSU, or other indications within the timeframe noted in the questionnaire. If prior biologic or targeted synthetic drug use is reported, attach chart notes, medical records, or claims history documenting the prior medication, dose, frequency, and duration.

Atopic dermatitis new-start: report biologic/targeted synthetic use within past 180 days
Asthma/COPD/CSU: report biologic use within the timeframe specified on the form
Attach supporting chart notes, medical records, or claims history for any prior biologic/targeted synthetic use

Denial Risk

Continuation Requests — Document Positive Clinical Response

For continuation requests, provide documentation that the patient has achieved or maintained a positive clinical response to the requested drug as specified for the indication (e.g., low disease activity or improvement in signs/symptoms for atopic dermatitis, improved asthma control or reduced exacerbations, improved CSU symptoms or reduced UAS7). ACTION REQUIRED: If the response is 'Yes', attach supporting chart notes or medical record documentation showing the clinical improvement. Lack of documentation of a positive clinical response for continuation requests may result in denial.

Attach chart notes showing objective or clinician-documented improvement for continuation requests
Positive response examples: clear/almost clear skin (AD), reduced exacerbations or steroid dose (asthma), decreased UAS7 (CSU)

Note

Administrative Patient and Prescriber Data — Provide on PA Form

Provide administrative patient and prescriber information on the PA form: patient name, HMSA patient ID, date of birth, contact phone, patient weight and height, ICD-10 code for the diagnosis, and indicate site of dispensing and site of administration. Include prescriber name, specialty, NPI, office telephone and fax. Failure to provide required administrative data may delay processing.

Patient demographics: name, ID, DOB, phone, weight (kg), height
Indicate site of drug dispensing and site of administration
Provide ICD-10 code and prescriber information: name, specialty, NPI, office phone and fax

Initial Therapy Requirements

Initial Therapy

Initial Therapy — new start requirements vary by indication and typically require prior trial/failure of specified topical, inhaled, systemic, or biologic therapies:

AD initial: No biologic or systemic targeted synthetic for atopic dermatitis in past 180 days; documentation of BSA and trials of two specified topical therapies (high‑potency topical corticosteroid, topical calcineurin inhibitor, topical JAK inhibitor, topical PDE‑4 inhibitor) within past 180 days or documented reasons to avoid them (attach supporting chart notes)

chunks 5-6

Asthma initial: No prior biologic for asthma in past year; evidence of uncontrolled asthma (exacerbations, hospitalization, or poor symptom control) and baseline pre‑treatment blood eosinophil count provided; documentation of inadequate control despite optimized ICS + additional controller or high‑dose ICS + controller + oral glucocorticoids where applicable (attach notes)eosinophils branch

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CRSwNP initial: No prior biologic for CRSwNP in past year; bilateral polyposis with chronic symptoms; intranasal corticosteroid trial >=4 weeks unless contraindicated; prior sino‑nasal surgery OR inadequate response to systemic corticosteroids within last 2 years OR contraindication to systemic corticosteroids; objective endoscopy/CT or Meltzer/NPS thresholds documentedNPS/Meltzer/endoscopy criteria

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EoE initial: Esophageal biopsy >=15 eosinophils per HPF and inadequate response to PPI and swallowed topical corticosteroids unless contraindicated (attach biopsy and treatment records)>=15 eos/hpf

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PN initial: No biologic for prurigo nodularis in past year; pruritus >=6 weeks; >=20 nodules; inadequate response to medium to super‑high potency topical corticosteroid and topical calcineurin inhibitor, phototherapy, and methotrexate/cyclosporine as applicable, or documented contraindication/intolerance (attach records)>=20 nodules

chunks 16-18

COPD initial therapy requirements

COPD initial therapy requirements — requires diagnostic confirmation and prior therapy documentation:

COPD_initial: Confirm adult status and prescriber specialty; provide spirometry showing FEV1/FVC < 0.7 post‑bronchodilation or classic COPD signs/symptoms; document prior maintenance inhaled therapies (ICS/LAMA/LABA or LAMA+LABA) and any contraindication to ICS; provide pre‑treatment absolute blood eosinophil count and exacerbation history; document prior biologic use in past year if present

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CSU initial therapy requirements

CSU initial therapy requirements — requires prior antihistamine optimization and evaluation for other causes:

CSU_initial: Prescriber specialty and age >=12; duration of spontaneous wheals/angioedema considered (>=6 weeks typical); documented inadequate response to up‑dosed second‑generation H1 antihistamines for at least 2 weeks per guideline recommendations; evaluation for alternative causes of wheals/angioedema completed and documented

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Criteria for Continuing Therapy

Continuation Therapy

Continuation Therapy — continuation requests generally require documentation of positive clinical response appropriate to the indication:

general continuation: Attach chart notes showing positive clinical response (examples vary by indication: AD — clear or almost clear skin; asthma — reduced exacerbations or steroid dose; CRSwNP — improved polyp size/symptoms; EoE — symptom improvement)

chunks 4,8,11,14

Continuation therapy documentation requirements

Continuation therapy documentation requirements — requires documentation of clinical benefit and relevant lab/test results depending on indication:

general_continuation: Attach chart notes demonstrating positive clinical response or maintenance of response; confirm drug source (not only samples/PAP) when requested; provide prior biologic history and required test results (spirometry, absolute blood eosinophil count) and exacerbation documentation where applicable

chunks 18,19,20,21,23

Step Therapy and Trial Requirements

Requirement	Details / Documentation
Step therapy requirement
Documentation required before approval for new starts: prior trials and responses to specified therapies or documented contraindication/intolerance

Requirement	Details / Documentation
Document failure or insufficient response to prior therapy
For chronic spontaneous urticaria, document inadequate response despite up‑dosing a second‑generation H1 antihistamine for at least 2 weeks (attach chart notes/medical records or claims history). Also document prior biologic use in past year if applicable and evaluation for other causes of wheals/angioedema.

Dispensing and Administration Site

Note

Provide site of dispensing and administration (no site restriction stated)

The PA form collects the site where the drug will be dispensed and where it will be administered (multiple options listed on the form); this excerpt does not impose an explicit site‑of‑care restriction.

Background

This PA form is structured to collect information for multiple indications for Dupixent (dupilumab), including but not limited to: atopic dermatitis (AD), asthma, chronic rhinosinusitis with nasal polyposis (CRSwNP), eosinophilic esophagitis (EoE), prurigo nodularis (PN), immune checkpoint inhibitor–related dermatologic toxicity, chronic obstructive pulmonary disease (COPD), and chronic spontaneous urticaria (CSU). For each indication the form collects indication-specific eligibility items (age and prescriber specialty), prior therapy trials or contraindications, objective disease measures (e.g., BSA for AD, biopsy eosinophil count for EoE, NPS/Meltzer for CRSwNP, eosinophil counts or spirometry for COPD), and documentation of response for continuation requests.

Clinical Definitions and Scoring Thresholds

CRSwNP scoring (NPS and Meltzer)

Nasal Polyp Score (NPS)Total endoscopic NPS >= 5 with minimum score of 2 per nostril

Meltzer Clinical ScoreMeltzer Clinical Score >= 2 in both nostrils is an alternative documented threshold

DocumentationAttach endoscopy/CT findings or chart notes documenting NPS/Meltzer scores

EoE biopsy threshold (repeat)

EoE biopsy criterion>= 15 intraepithelial eosinophils per high power field

Evidence to attachAttach endoscopic biopsy report with eosinophil count as supporting documentation

COPD spirometry confirmation

Spirometry confirmation for COPDDiagnosis confirmed by spirometry showing FEV1/FVC < 0.7 post-bronchodilation

Documentation requiredAttach chart notes or spirometry report showing post-bronchodilator FEV1/FVC

Alternate evidenceIf spirometry not available, classic COPD signs/symptoms may be considered per form instructions (attach documentation)

Eosinophil threshold (COPD)

Eosinophil threshold prior to therapy>= 300 cells per microliter

TimingReport absolute blood eosinophil count prior to initiating therapy (before significant oral steroid use)

DocumentationAttach chart notes or lab report showing eosinophil count

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request Form — Dupixent (dupilumab)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization to CVS Caremark (fax 1-866-237-5512) with the completed indication-specific questionnaire and required supporting chart notes/records.

SourceLink

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eosinophils >=150 cells/uL branch

NPS >=5 with min 2 per nostril or Meltzer >=2