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Dupixent (dupilumab) prior authorization request - coverage criteria

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This form governs prior authorization requests for Dupixent (dupilumab) across multiple labeled indications and is intended for providers requesting coverage for Highmark West Virginia members.

Policy Summary

PayerHighmark West Virginia

PolicyDupixent (dupilumab) prior authorization request - coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Dupixent prior authorization form with diagnosis, dosing, weight, clinical documentation, medication history, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleIndications on form

4Presentation options

28/84Day supply choices

kgWeight collected

Coverage criteria by indication

Indication-level coverage

Coverage is assessed per indication when the corresponding indication-specific criteria are met.

Covered indications: Atopic dermatitis; eosinophilic esophagitis; asthma; chronic rhinosinusitis with nasal polyposis; prurigo nodularis; COPD; chronic spontaneous urticaria; bullous pemphigoid

Provider must complete the section corresponding to the chosen indication and supply objective measures and prior therapy history.

Moderate-to-severe atopic dermatitis

Atopic dermatitis specific considerations

Atopic dermatitis baseline requirements: Prescribed by a dermatologist, allergist, immunologist, or other appropriate specialist; therapeutic failure or intolerance to a generic topical corticosteroid, topical tacrolimus, or topical pimecrolimus; member incapable of applying topical therapies due to extent of BSA involvement OR severe atopic dermatitis with severely damaged skin; indicate if member is currently on Dupixent and, if so, whether there is a positive clinical response.

If currently on Dupixent, provider must indicate positive clinical response to continue therapy.

Eosinophilic esophagitis

Eosinophilic esophagitis specific requirements

EoE requirements: Esophageal eosinophil count >= 15 eos/hpf on esophageal biopsy; clinical symptoms of esophageal dysfunction (for example, dysphagia, food impaction, gastroesophageal reflux); history of EoE signs or symptoms; at least two episodes of dysphagia per week; therapeutic failure, intolerance, or contraindication to high‑dose proton‑pump inhibitor therapy (for example, omeprazole or pantoprazole 80 mg/day); indicate if member is currently on Dupixent and document histological remission or symptom response if applicable.>=15 eos/hpf

Form captures histological remission and symptom response if currently on therapy.

Moderate-to-severe asthma

Asthma specific requirements

Asthma requirements: Provide prebronchodilator FEV1; evidence of FEV1 reversibility >= 12% and 200 mL after albuterol OR a history of >=2 exacerbations requiring systemic corticosteroids (or >=1 hospitalization) in the prior 12 months; eosinophilic phenotype with blood eosinophils >= 150 cells/µL; inadequate control despite medium- or high-dose inhaled corticosteroids plus at least one additional controller; member will continue controller therapy while on Dupixent; indicate current Dupixent use and document clinical response measures (decreased rescue medication or oral corticosteroid use, decreased exacerbation frequency, increased pulmonary function, or symptom reduction) if applicable.FEV1 reversibility >=12% and 200 mL; eos >=150 cells/µL

Also captures oral corticosteroid use and reductions in exacerbations/function as continuation criteria.

Chronic rhinosinusitis with nasal polyposis (CRSwNP)

CRSwNP requirements: Provide baseline bilateral nasal polyp score (0–8) and baseline nasal congestion score (0–3); therapeutic failure, intolerance, or contraindication to an intranasal corticosteroid and to a 14‑day course of oral corticosteroids; indicate current Dupixent use and document response (decrease in nasal polyp score or reduction in nasal congestion) if applicable.Nasal polyp score 0-8; congestion 0-3

Form requests objective baseline scores (sum of left and right nostril scores).

Prurigo nodularis

Prurigo nodularis — indication-specific criteria

Prurigo nodularis requirements: Prescribed by a dermatologist, allergist, immunologist, or other appropriate specialist; at least 10 identifiable nodular lesions; therapeutic failure, intolerance, or contraindication to one generic topical corticosteroid; member incapable of applying topical therapies due to extent of BSA involvement OR severely damaged skin; indicate current Dupixent use and document response (reduction in itch or lesion count) if applicable.>=10 nodules

Form captures reduction in itch or lesion count if on therapy.

Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) — indication-specific criteria

COPD requirements: Provide post‑bronchodilator FEV1 percent predicted; blood eosinophil count; mMRC dyspnea scale score; whether currently taking daily or alternate‑day oral corticosteroids; history of >=2 moderate exacerbations requiring systemic corticosteroids and/or antibiotics in the prior year OR >=1 severe exacerbation resulting in hospitalization or observation >24 hours; documentation that COPD is GOLD group E; inadequate symptom control despite >=3 months of triple therapy (LAMA + LABA + ICS) or intolerance/contraindication to those agents; indicate current Dupixent use and document response (reduction in COPD symptoms, improved exercise tolerance, delayed progression, or reduced exacerbations) if applicable.

Form captures multiple objective COPD measures to support use.

Chronic spontaneous urticaria (CSU)

Chronic spontaneous urticaria (CSU) — indication-specific criteria

CSU requirements: Therapeutic failure, intolerance, or contraindication to one second‑generation non‑sedating H1 antihistamine at maximum recommended doses (for example: cetirizine, desloratadine, levocetirizine); indicate current Dupixent use and document improvement in CSU symptoms while on therapy if applicable.

Form asks about prior antihistamine failure.

Bullous pemphigoid

Bullous pemphigoid — indication-specific criteria

Bullous pemphigoid requirements: Prescribed by a dermatologist, allergist, immunologist, or other appropriate specialist; therapeutic failure, intolerance, or contraindication to oral corticosteroids and to high‑ or super‑high‑potency topical corticosteroids; indicate current Dupixent use and document clinical response (disease control, reduction in relapses, improvement in symptoms, or reduction in oral corticosteroid use) if applicable.

Form captures clinical response and reduction in oral steroid need.

The prior authorization form does not list any explicit exclusions. The form asks the prescriber to specify the Dupixent product presentation and the diagnosis/ICD-10 code(s) but contains no section enumerating conditions or situations that are expressly excluded from coverage.

The form itself does not define specific not medically necessary conditions. It requires the provider’s attestation that the requested services are medically indicated and necessary, and notes that payment is subject to member eligibility and that an authorization decision does not guarantee payment.

Diagnosis, lab thresholds, and measurement values

Requested diagnosis/ICD-10ICD-10

none listed

Form requests 'Diagnosis and/or ICD-10 codes(s):' but lists no specific codes

Eosinophils per high power field (EoE) — >= 15 eos/hpf

Eosinophil threshold (EoE)>= 15 eos/hpf on esophageal biopsy

Clinical requirementClinical symptoms of esophageal dysfunction (eg, dysphagia, food impaction, GERD)

Prior therapy requirementTherapeutic failure, intolerance, or contraindication to high‑dose PPI therapy

FEV1 reversibility — >= 12% and 200 milliliters after albuterol

Reversibility threshold>= 12% and >= 200 milliliters increase in FEV1 after albuterol

Measure requestedPrebronchodilator FEV1 (percent) must be provided

Alternative asthma criteriaHistory of >=2 exacerbations requiring systemic corticosteroids or >=1 hospitalization in prior 12 months

Asthma exacerbation history — >= 2 exacerbations requiring systemic corticosteroids in prior 12 months (or >=1 hospitalization)

Exacerbation threshold>= 2 exacerbations requiring oral or injectable systemic corticosteroids in prior 12 months

Hospitalization alternative>= 1 asthma exacerbation requiring hospitalization in prior 12 months (alternative criterion)

DocumentationForm asks for history of exacerbations and current oral corticosteroid use

Nasal Polyp Score (baseline) — 0-8 (sum of two nostrils)

Score range0–8 (sum of right and left nostril scores)

Per‑nostril scoringEach nostril scored 0–4; total = left + right

UseBaseline bilateral nasal polyp score requested on form

Member weight — kilograms (requested)

Weight (requested)Member's weight in kilograms (required to support dosing)

Dosing relevanceWeight is requested to support dosing where applicable (initial/maintenance) and selection of presentation

Submission and documentation requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Complete the Dupixent request form specifying the exact product requested, diagnosis/ICD-10 code(s), and dosing (induction and maintenance where applicable). Include prescriber information (physician name, NPI, phone, fax, address, city, state, zip, suite/building) and the physician signature and date.

Specify product: Dupixent 200mg/1.14ml syringe; Dupixent 300mg/2ml syringe; Dupixent 200mg/1.14ml pen; Dupixent 300mg/2ml pen
Provide diagnosis and ICD-10 code(s)
Include dosing schedule (induction and maintenance) and whether member is currently on Dupixent

Step Therapy

Step Therapy / Prior Treatment Failures

Step therapy and prior treatment failures must be documented on the form. Indicate whether the member experienced therapeutic failure, intolerance, or has a contraindication to the specified prior therapies relevant to the diagnosis being treated.

Atopic dermatitis: document failure/intolerance to generic topical corticosteroids, topical tacrolimus, or topical pimecrolimus; note inability to apply topicals due to BSA when applicable
Eosinophilic esophagitis: document failure/intolerance/contraindication to high‑dose PPI therapy
Chronic rhinosinusitis with nasal polyposis: document failure/intolerance/contraindication to intranasal corticosteroid and to a 14‑day course of oral corticosteroids
Chronic spontaneous urticaria: document failure/intolerance/contraindication to one second‑generation non‑sedating H1 antihistamine at maximum recommended doses
Bullous pemphigoid: document failure/intolerance/contraindication to oral corticosteroids and high‑potency topical corticosteroids

Documentation Required

Submission Instructions

Fax or mail the completed form with all required clinical documentation. Include the physician address (required for physician notification) and the prescriber's signature certifying the information is true and complete.

Fax to: 1-866-240-8123
Mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
Submit a separate form for each medication request; print or type legibly in blue or black ink; the prescribing physician should generally complete the form

Denial Risk

Payment and Authorization Note

Payment is subject to member eligibility. An authorization, if issued, does not guarantee payment.

The submitting provider certifies the information is true, accurate, and complete and that the requested services are medically indicated and necessary
Authorization decisions are independent of final payment determination based on member eligibility and benefits

Initial therapy dosing and supply

Initial therapy dosing

Dosing and supply — provider must indicate product presentation, requested quantity, and day supply.

Product selection and dosing: Provider must indicate product presentation (Dupixent 200 mg/1.14 mL or Dupixent 300 mg/2 mL; syringe or pen), whether induction dosing is required, number of pens/syringes requested, and requested day supply (28 days, 84 days, or other).

Member weight is requested to support dosing where applicable.

Requirements for continuing therapy

Continuation therapy evidence

Continuation therapy documentation requested for members already on Dupixent.

Continuation response measures: If currently on Dupixent, provider must indicate clinical response measures such as decreased rescue medication or oral corticosteroid use, decreased frequency of severe exacerbations, increased pulmonary function, reduction in symptoms, decreased nasal polyp score or congestion, histological remission in EoE (<15 eos/hpf), reduction in itch or nodules, or reduction in relapses for bullous pemphigoid.

Used to support ongoing therapy.

Prior treatment and step requirements

Requirement	Form field / provider action
Indicate prior therapeutic failure, intolerance, or contraindication to specified prior therapies (per indication)	Select applicable prior therapy failures/intolerances on the form (examples: generic topical corticosteroid; generic topical tacrolimus; generic topical pimecrolimus; high‑dose PPI for EoE; intranasal corticosteroid or 14‑day oral corticosteroid for CRSwNP; second‑generation non‑sedating H1 antihistamine for CSU; oral corticosteroids or high‑potency topical corticosteroids for bullous pemphigoid)
If currently on Dupixent, document clinical response to therapy when applicable	Check 'Yes' and select response items on the form (examples: decreased exacerbations or rescue medication use, increased pulmonary function, decreased nasal polyp score/congestion, histological remission in EoE, reduction in itch or nodules, reduction in relapses for bullous pemphigoid)
Provider must complete the section corresponding to the chosen indication and supply objective measures and prior therapy history	Complete indication‑specific fields on the form (examples: eosinophil count ≥15 eos/hpf for EoE; baseline bilateral nasal polyp score 0–8 for CRSwNP; FEV1 and reversibility or exacerbation history for asthma; ≥10 nodules for prurigo nodularis)
Provide medication history of other therapies tried and failed	Use the Medication History section to list other medications the member has tried and failed and attach supporting clinical documentation as instructed

Requested supply and quantity

Dupixent (dupilumab) — Requested number of pens/syringes as provided by prescriber

Quantity requestedRequested number of pens/syringes as provided by prescriber (entered on Maintenance Dosing section)

Day supply optionsRequested day supply choices on form: 28 days, 84 days, or other

Presentation selectionProvider must indicate product presentation (200 mg/1.14 mL or 300 mg/2 mL syringe/pen) when requesting quantity

Site-of-care restrictions

Note

No explicit site‑of‑care restrictions on the form

The form does not impose any explicit site‑of‑care restrictions; follow the standard submission and instructions for processing.

Use the standard fax or mail submission pathways listed on the form.
No separate site‑of‑care field or restriction is specified on the request form.

Clinical background

Dupixent (dupilumab) is requested across multiple inflammatory conditions on the form, including moderate-to-severe atopic dermatitis, eosinophilic esophagitis, asthma with an eosinophilic phenotype, chronic rhinosinusitis with nasal polyposis, prurigo nodularis, chronic obstructive pulmonary disease, chronic spontaneous urticaria, and bullous pemphigoid. The form collects indication-specific objective measures (for example, esophageal eosinophil counts, FEV1 and reversibility, blood eosinophils, nasal polyp score, mMRC score, and nodular lesion counts) and documents prior therapy history to support medical necessity and continuation of therapy when applicable.

Clinical score definitions and scales

Nasal Polyp Score — Sum of right and left nostril scores (each 0–4) for a total score 0–8

DefinitionSum of right and left nostril scores (each scored 0–4) for a total score 0–8

Per‑nostril scaleEach nostril scored 0 = no polyp to 4 = large polyp

Use on formBaseline bilateral nasal polyp score (0–8) is requested to characterize nasal polyps

mMRC dyspnea scale — Modified Medical Research Council dyspnea scale used to assess baseline functional disability due to dyspnea.

Scale purposeModified Medical Research Council (mMRC) dyspnea scale assesses baseline functional disability due to dyspnea

Form fieldForm requests the member's mMRC score for COPD assessment

Context of usemMRC score used alongside post‑bronchodilator FEV1 and blood eosinophil count to support COPD indication

Policy Summary

PayerHighmark West Virginia

PolicyDupixent (dupilumab) prior authorization request - coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Dupixent prior authorization form with diagnosis, dosing, weight, clinical documentation, medication history, and prescriber signature.

SourceLink

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