Dupixent (dupilumab) prior authorization request form coverage criteria
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Form and clinical intake questions used to request prior authorization for Dupixent (dupilumab) for multiple indications (atopic dermatitis, asthma, eosinophilic esophagitis, chronic rhinosinusitis with nasal polyposis, prurigo nodularis, COPD, chronic spontaneous urticaria). Affects prescribing providers and prior authorization reviewers for Highmark BlueShield NE/NY membership.
No material clinical or coverage changes in this revision.
Coverage Criteria and Indication-Specific Intake
Intake criteria per indication
Covered when the indication-specific objective findings and prior therapy history listed on the intake form are documented; the form collects the following grouped elements per indication.
From atopic dermatitis section of form
From EoE section of form
From asthma section of form
From CRSwNP section of form
From prurigo nodularis section of form
From COPD section of form
From CSU section of form
The prior authorization form collects indication-specific clinical findings and prior therapy history to support a determination that Dupixent (dupilumab) is medically necessary. For each covered diagnosis the form requests objective measures (for example, esophageal biopsy eosinophil count for EoE; pre‑ and post‑bronchodilator FEV1 and blood eosinophils for asthma; bilateral nasal polyp score for CRSwNP; mMRC score and exacerbation history for COPD) and documentation that the member has had therapeutic failure, intolerance, or a contraindication to specified prior therapies. The form also asks whether the member previously received Dupixent and, if so, to document clinical response to therapy.
The form does not list explicit absolute exclusions. Instead, it requests documentation of contraindications or intolerance to prior therapies where relevant to the indication (for example, inability to use topical therapies due to extensive BSA or severely damaged skin for atopic dermatitis; failure/intolerance/contraindication to high‑dose PPI for EoE; failure/intolerance/contraindication to intranasal corticosteroids or a 14‑day oral corticosteroid course for CRSwNP; maximum‑dose antihistamine failure for CSU). Reviewers should base coverage decisions on the presence of the required objective findings and prior therapy history documented on the form.
Completion of the form and any authorization determination do not guarantee payment: payment is subject to member eligibility and authorization does not guarantee payment. Providers must supply complete and accurate documentation to support medical necessity and verify member benefit coverage with the plan.
Medication Presentations, Key Clinical Thresholds, and Supply
| Dupixent 200mg/1.14ml syringe | listed product presentation |
| Dupixent 30Omg/zml syringe | listed product presentation (as printed) |
| Dupixent 200mg/1.14ml pen | listed product presentation |
| Dupixent 300mg/2ml pen | listed product presentation |
Submission Requirements and Provider Responsibilities
Prior authorization: complete medication, diagnosis, and dosing fields
Specify the exact Dupixent product presentation being requested, the diagnosis and ICD‑10 code(s), dosing (indicate if induction dosing is required and provide induction details if applicable), maintenance quantity (number of pens/syringes) and requested day supply, member weight (kg) when requested, and complete provider/member identifying details on a separate form per medication submission.
- Select one listed presentation: Dupixent 200mg/1.14ml syringe; Dupixent 300mg/2ml pen; Dupixent 200mg/1.14ml pen; (document also lists Dupixent 30Omg/zml syringe as printed).
- Enter diagnosis and ICD‑10 code(s).
- Indicate whether induction dosing is required and provide induction regimen if applicable.
- Provide maintenance dosing: number of pens/syringes and requested day supply (28 days, 84 days, or Other with directions).
- Include member weight in kilograms when requested on the dosing section.
- Submit a separate completed form for each medication.
Document prior therapy failures, intolerances, or contraindications
For each indication, document therapeutic failure, intolerance, or contraindication to the prior therapies listed on the form (the form requires selecting applicable prior therapy failures/intolerances or contraindications).
- Atopic dermatitis: failure or intolerance to a generic topical corticosteroid and/or generic topical tacrolimus or pimecrolimus, or documentation that topical therapy cannot be applied due to extent of BSA or severely damaged skin.
- Eosinophilic esophagitis: failure, intolerance, or contraindication to high‑dose PPI therapy (e.g., omeprazole or pantoprazole 80 mg/day).
- Chronic rhinosinusitis with nasal polyposis: failure, intolerance, or contraindication to intranasal corticosteroid and to a 14‑day course of oral corticosteroids.
- Prurigo nodularis: failure, intolerance, or contraindication to one generic topical corticosteroid or inability to apply topicals due to BSA/severely damaged skin.
- COPD: inadequate control despite at least 3 months of triple therapy (LAMA + LABA + ICS) or intolerance/contraindication to these agents.
- Chronic spontaneous urticaria: failure, contraindication, or intolerance to antihistamines at maximum recommended doses (e.g., cetirizine, desloratadine, levocetirizine).
Submission instructions: complete form, include physician address and signature, fax or mail
Complete all sections of the form, include the prescribing physician’s address and signature, and fax or mail the completed form with supporting clinical documentation to the SPECARE contact shown on the form.
- Submit a separate form for each medication.
- Provide physician name, NPI, phone, fax, full address (including suite/building, city, state, zip), physician signature, and date.
- Fax the completed form and clinical documentation to 1‑866‑240‑8123 or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
Risk of denial for incomplete or missing information; authorization/payment not guaranteed
Missing or incomplete required information on the form may result in denial of the request; also note that authorization does not guarantee payment and payment is subject to member eligibility.
- The submitting provider certifies information is true, accurate, and complete; incomplete or missing required information may lead to denial.
- Payment is subject to member eligibility and authorization does not guarantee payment.
Clinical Background
Dupixent (dupilumab) is an anti‑IL‑4/IL‑13 monoclonal antibody requested on this form for multiple type‑2 inflammatory and eosinophilic conditions, including moderate‑to‑severe atopic dermatitis, moderate‑to‑severe asthma with eosinophilic phenotype, eosinophilic esophagitis, chronic rhinosinusitis with nasal polyposis, prurigo nodularis, chronic obstructive pulmonary disease, and chronic spontaneous urticaria. The intake questions capture disease‑specific objective measures (for example, esophageal eosinophils, blood eosinophil count, FEV1, nasal polyp score, mMRC) and prior treatment history to support assessment of medical necessity for initiation or continuation of therapy.
Scoring Systems and Scales
Dosing, Supply, and Initiation Requirements
Dosing and supply
Document dosing details on the prior authorization form; specify induction dosing if required and the requested maintenance quantity and day supply.
From induction dosing question on form
From maintenance dosing section on form
From maintenance dosing day supply options on form
Member weight in kg is required per form fields
Continuation and Response Documentation
Continuation/response documentation
For members previously treated with Dupixent, the form requires documentation of clinical response items to support continuation of therapy.
Multiple response items captured across indication sections of the form
Prior Therapy and Step Requirements
| Indication | Prior therapies to document failure/intolerance/contraindication |
|---|---|
| Atopic dermatitis | Generic topical corticosteroid; generic topical tacrolimus; generic topical pimecrolimus; note ability to apply topicals (extensive BSA) or severely damaged skin if topicals not feasible |
| Eosinophilic esophagitis (EoE) | High‑dose proton‑pump inhibitor therapy (for example omeprazole or pantoprazole 80 mg/day) — document failure, intolerance, or contraindication |
| Asthma | Inadequate control on medium‑ or high‑dose inhaled corticosteroid plus at least 1 additional controller (e.g., LABA, leukotriene receptor antagonist, theophylline) — document failure/intolerance/contraindication; also record exacerbation history and eosinophilic phenotype per form |
| Chronic rhinosinusitis with nasal polyposis (CRSwNP) | Intranasal corticosteroid; 14‑day course of oral corticosteroids — document therapeutic failure, intolerance, or contraindication |
| Prurigo nodularis | One generic topical corticosteroid — document therapeutic failure, intolerance, or contraindication; note inability to apply topicals due to BSA or severely damaged skin |
| Chronic obstructive pulmonary disease (COPD) | At least 3 months of triple therapy (LAMA + LABA + inhaled corticosteroid) — document inadequate symptom control or intolerance/contraindication |
| Chronic spontaneous urticaria (CSU) | Antihistamine at maximum recommended doses (for example cetirizine, desloratadine, levocetirizine) — document therapeutic failure, intolerance, or contraindication |
Quantity and Request Limits
Site of Care and Submission Destination
Site‑of‑care: no explicit restrictions; submit via SPECARE fax/mail
The form does not impose a site‑of‑care restriction; submit standard prior authorization requests for Dupixent via the SPECARE fax or mail process noted on the form.
- No explicit infusion center or site‑of‑care limitation is listed on the form.
- Use the same fax (1‑866‑240‑8123) or mailing address (120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222) for submission.
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