CurrentUnitedHealthcarePolicy N/A

Dupixent (dupilumab) prior authorization for atopic dermatitis

This document is an authorization request form for Dupixent (dupilumab) to treat moderate to severe atopic dermatitis in beneficiaries, capturing patient, prescriber, drug, and clinical information required for coverage and continuation.

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization for atopic dermatitis

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with patient/prescriber/drug details and document age ≥6 years, diagnosis of moderate to severe atopic dermatitis, and at least one failed prescription topical steroid or a documented contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6+Minimum age

1Prior steroid trial required

180Max therapy length (days)

Q1-6Continuation doc required

Coverage Criteria for Dupixent (dupilumab)

Initial therapy criteria

Coverage request requires ALL of the following to be indicated/completed on the form when initiating therapy

Patient eligibility: Beneficiary is 6 years of age or older and has a diagnosis of moderate to severe atopic dermatitis.age >= 6 years

Captured by questions 1 and 2 on the form

Prior topical steroid trial or contraindication: Either failed at least one prescription topical steroid OR has a documented adverse reaction or contraindication that precludes trial of at least one prescription topical steroid.at least 1 failed topical steroid or documented contraindication

Captured by question 3 and the subsequent contraindication field on the form

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization for atopic dermatitis

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Treatment requests should include documentation that the beneficiary meets the clinical and prior‑therapy requirements captured on the form. If the beneficiary is under 6 years of age, the form’s age question indicates they do not meet the minimum age eligibility and the request may be denied as not meeting coverage criteria. Similarly, requests lacking a documented diagnosis of moderate to severe atopic dermatitis (Question 2) or failing to show either a trial of at least one prescription topical steroid (Question 3) or a documented contraindication to such a trial (follow‑up field) do not satisfy the form’s required items. For continuation requests, failure to provide medical records demonstrating continued clinical benefit from baseline (Question 6) also risks a determination that therapy is not medically necessary.

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required before UnitedHealthcare will approve coverage. The prior authorization form must be completed in full, including patient and prescriber details, the requested drug, dose/strength, quantity, length of therapy, and confirmation that the beneficiary meets clinical criteria for therapy.

Prior authorization form must include: beneficiary demographics, prescriber NPI and contact, drug name/strength/quantity, and requested length of therapy.
Complete prescriber signature and date are required.

Denial Risk

Documentation and Prior-Trial Deficiencies May Cause Denial

The form requires documentation that the beneficiary is age ≥ 6 years and has a diagnosis of moderate to severe atopic dermatitis. Failure to document required clinical details or prior trials may result in denial or a request for additional information.

Must confirm beneficiary is 6 years of age or older.
Must document diagnosis of moderate to severe atopic dermatitis.
Incomplete or missing clinical information, or lack of required prior-trial documentation, increases denial risk or may trigger requests for medical records.

Documentation Required

Required Submission Elements

The prior authorization form must include all required submission elements. Provide complete beneficiary demographics, prescriber NPI and requester contact information (name and phone), drug name, strength, quantity per 30 days, and requested length of therapy. Prescriber signature and date are mandatory.

Beneficiary: last name, first name, beneficiary ID #, date of birth, gender.
Prescriber: prescribing provider NPI #, requester contact name and phone number (and extension if applicable).
Drug: drug name, strength, quantity per 30 days, length of therapy (select up to 30/60/90/120/180 days).
Signed prescriber attestation certifying accuracy of submitted information.

Step Therapy

Topical Steroid and Calcineurin Inhibitor Trial Requirement

A documented trial of at least one prescription topical steroid is required prior to approval unless there is a documented adverse reaction or contraindication. The form also asks whether a topical calcineurin inhibitor trial is precluded by adverse reaction/contraindication and requests listing of contraindications when applicable.

Document whether beneficiary has failed at least one prescription topical steroid; if yes, list agent(s) tried.
If no trial was done, provide documentation of an adverse reaction or contraindication that precludes topical steroid use.
If topical calcineurin inhibitors are not appropriate, provide documented adverse reaction or contraindication (e.g., pimecrolimus or tacrolimus with age-appropriate concentrations).

Policy Background and Intended Use

This prior authorization form is intended to document eligibility for Dupixent (dupilumab) in patients with moderate to severe atopic dermatitis. It captures the beneficiary’s age (minimum captured age: 6 years), the presence of a documented diagnosis of moderate to severe atopic dermatitis, prior topical therapy history including whether the beneficiary has failed at least one prescription topical steroid or has a documented adverse reaction/contraindication that precludes such a trial, and any contraindication to topical calcineurin inhibitors where applicable. For continuation of therapy the form requires attestation and submission of medical records demonstrating continued clinical benefit from baseline while on Dupixent, and prescriber signature and date.

Definitions and Clinical Terms

Moderate to severe Atopic Dermatitis

DefinitionDocumented diagnosis of moderate to severe atopic dermatitis as indicated on the form (the form itself does not provide clinical severity criteria).

Form fieldQuestion 2 on the form asks: 'Does the beneficiary have a diagnosis of moderate to severe Atopic Dermatitis?' with Yes/No response options.

Age contextThe form captures age eligibility separately (Question 1: beneficiary 6 years of age or older), which is required alongside the diagnosis for coverage consideration.

Use in documentationA provider must indicate the diagnosis on the form; absence of this documented diagnosis may render the request not medically necessary.

Failure of prescription topical steroid

DefinitionA documented unsuccessful trial of at least one prescription topical corticosteroid, or a documented adverse reaction/contraindication preventing such a trial.

Form fieldsQuestion 3: 'Has the beneficiary failed at least one prescription topical steroid?' (Yes/No) and a follow-up field to 'Please List' the agent(s).

Contraindication captureThe form also asks: 'Does the beneficiary have a documented adverse reaction or contraindication that precludes trial of at least 1 prescription topical steroid? Yes/No' with space to list contraindications.

Topical calcineurin inhibitor noteThe form additionally asks about documented adverse reaction/contraindication to topical calcineurin inhibitors (pimecrolimus or tacrolimus) when relevant.