Prior authorization required — document diagnosis, extent, specialty, age, treatment and dosing

Prior authorization is required. Provider must document the diagnosis, extent of disease (BSA ≥10% or involvement of specified special areas), prescribing clinician specialty (prescribed by or in consultation with a dermatologist or allergist), patient age (≥12 years), treatment history, and dosing limits to support initial approval.

• Demonstrate diagnosis and extent of disease per policy (BSA ≥10% or involvement of hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas).
• Confirm prescriber is a dermatologist or allergist or that the request is in consultation with one.
• Provide age verification (patient ≥ 12 years), prior treatment history, and planned dose (≤100 mg/day or justification for 200 mg/day).

Step therapy — topical and systemic agent failures required before approval

Step therapy must be documented before approval: failure of topical corticosteroids and a non‑steroidal topical therapy is required, and failure of Dupixent and Rinvoq each for > consecutive 4 months is also required unless contraindicated or not tolerated.

• Failure of two formulary medium to very high potency topical corticosteroids, each used for ≥2 weeks.
• Failure of one non‑steroidal topical therapy used for ≥4 weeks (e.g., topical calcineurin inhibitor or Eucrisa).
• Failure of Dupixent and Rinvoq, each used for > consecutive 4 months, unless clinically significant adverse effects occur or both are contraindicated.
• Illinois HIM requests: step therapy requirements do not apply as of 1/1/2026 per IL HB 5395 (where applicable).

Required clinical documentation — submit office notes, labs, and prior-therapy records

Submit supporting clinical documentation with the authorization request: office chart notes, lab results, or other clinical information demonstrating the member meets all approval criteria.

• Office visit/chart notes documenting diagnosis, BSA or special-area involvement, symptoms and response to prior therapies.
• Records of prior topical therapy use (agents, potency, duration) and systemic biologic/JAK inhibitor therapy with dates and reasons for discontinuation.
• Documentation of prescriber specialty or consultation with a dermatologist/allergist, and dosing rationale if requesting >100 mg/day.

Documentation-based denials — missing required records or insufficient off‑label evidence may lead to denial

Requests missing required documentation that the member meets all approval criteria, or requests for non‑FDA indications without sufficient off‑label evidence, may be denied.

• Lack of documentation showing required topical/systemic treatment failures, prescriber specialty, age, extent of disease, or dosing justification may result in denial.
• Non‑FDA uses not addressed by this policy require sufficient documentation of efficacy and safety per off‑label use policies; otherwise coverage is not authorized.

Prior authorization guidance — policy as a guide to coverage decisions and benefits administration

This clinical policy is a guide to medical necessity to assist coverage decisions and administering benefits; prior authorization requirements are determined per the Health Plan and membership documents.

• Use this policy to inform coverage decisions and benefit administration, but follow Health Plan-specific prior authorization procedures and membership terms.
• The policy does not guarantee payment and may be changed by the Health Plan as needed.

Preferred-agent redirection — Dupixent and Rinvoq included in step requirements

Initial approval criteria were adapted to redirect to preferred agents Dupixent and Rinvoq; failure of these preferred agents (used > consecutive 4 months each) is required unless contraindicated or adverse effects occur.

• Policy creation note added redirection to preferred agents Dupixent and Rinvoq for atopic dermatitis initial approval.
• Failure of Dupixent and Rinvoq, each used for > consecutive 4 months, is required unless clinically significant adverse effects occur or both are contraindicated.

Provider professional judgment — apply clinical judgment; coverage still subject to plan terms

Coverage determinations guided by this clinical policy remain subject to the terms of the member's coverage documents; providers are expected to exercise professional medical judgment when treating patients.

• Providers should apply their clinical judgment; this policy is not intended to dictate medical practice.
• Coverage and administration of benefits remain subject to all plan terms, conditions, exclusions, limitations, and applicable law.

Coverage terms and limitations — determinations subject to plan documents, exclusions, and legal requirements

All coverage decisions and benefit administration are subject to the member's evidence of coverage, certificate of coverage, policy, contract, exclusions, limitations, and applicable state/federal requirements and Health Plan administrative policies.

• Decisions must conform to the specific plan's terms, conditions, exclusions, and limitations.
• Non‑FDA indications not addressed in this policy are excluded unless sufficient off‑label documentation is provided per off‑label use policies.