CurrentUnitedHealthcarePolicy N/A

Dupixent (Dupilumab) for Prurigo Nodularis

Authorization form / prior authorization questionnaire for Dupixent (dupilumab) for beneficiaries with Prurigo Nodularis, gathering patient, prescriber, drug and clinical trial/response information to support initiation or continuation of therapy.

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (Dupilumab) for Prurigo Nodularis

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete the Dupixent PA form including beneficiary, prescriber, drug and clinical information and provide medical records to obtain authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

Prurigo NodularisTarget Indication

18+Minimum Age

1Required prior topical steroid trial

Coverage Summary

Scope: Authorization form / prior authorization questionnaire for Dupixent (dupilumab) for beneficiaries with Prurigo Nodularis, gathering patient, prescriber, drug and clinical trial/response information to support initiation or continuation of therapy. Status: CURRENT.

Initial Therapy / Eligibility Criteria

Initial Therapy / Eligibility

Authorization supported when ALL of the following are met:

ALL of the following

Age: Beneficiary is age 18 years of age or older
Question on form: Yes/No
Diagnosis: Beneficiary has a diagnosis of Prurigo Nodularis
Question on form: Yes/No

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (Dupilumab) for Prurigo Nodularis

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete the Dupixent PA form including beneficiary, prescriber, drug and clinical information and provide medical records to obtain authorization.

SourceLink

On This Page

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Continuation of Therapy Criteria

Continuation of Therapy

Authorization for continuation supported when ALL of the following are met:

ALL of the following

Continued benefit: Prescriber confirms continued clinical benefit from baseline while on Dupixent, supported by medical records
Question on form: Yes/No; medical records must be provided documenting current Prurigo Nodularis status and response to Dupixent
Form completion: Prescriber answers questions 1-5 for continuation (age, diagnosis, prior topical steroid trial/contraindication, specialty prescriber, continued benefit)
Form requires completion of items 1-5 for continuation

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Providers must complete this Dupixent PA form including beneficiary, prescriber, drug and clinical information to obtain authorization.

Documentation Required

Medical records to support diagnosis and response

Provide medical records documenting the beneficiary's current Prurigo Nodularis status and response to Dupixent; this is required for continuation of therapy to demonstrate continued clinical benefit.

Documentation Required

Prescriber specialty requirement

Dupixent must be prescribed by or in consultation with a dermatologist, allergist, or immunologist. If prescribed in consultation, document the consultation on the form.

Documentation Required

Prescriber attestation/signature

Prescriber signature and date are required on the form. The prescriber must sign to certify the accuracy of the information provided.

Clinical Evidence & Definitions

This document is a pharmacy prior authorization (PA) request form for Dupixent (dupilumab) for Prurigo Nodularis. It collects beneficiary demographics (name, ID, date of birth, gender), prescriber NPI and requester contact information, and drug selections including strength, quantity per 30 days, and length of therapy options (up to 30, 60, 90, 120, 180, 365 days or other). The form contains clinical questions to establish initial or continued medical necessity (age ≥18, diagnosis of Prurigo Nodularis, prior trial/failure or contraindication/intolerance to at least one preferred medium to very high potency topical steroid, specialty prescriber or consultation requirement, and documentation of continued clinical benefit for continuation). Definitions: Prurigo Nodularis — clinical diagnosis referenced on the form; a specific clinical definition is not provided in this document.

OpenPayer

Dupixent (Dupilumab) for Prurigo Nodularis

Coverage Summary

Initial Therapy / Eligibility Criteria

Continuation of Therapy Criteria

Provider Actions & Prior Authorization

Applicable Codes

Clinical Evidence & Definitions

Revision History