CurrentUnitedHealthcarePolicy N/A

Dupixent (dupilumab) for Prurigo Nodularis prior authorization

Prior authorization request form to evaluate medical necessity for Dupixent (dupilumab) to treat Prurigo Nodularis in beneficiaries; completed by prescribers (dermatologist, allergist, or immunologist) and used by UnitedHealthcare for coverage decisions.

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) for Prurigo Nodularis prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm beneficiary is ≥18, has Prurigo Nodularis, tried ≥1 preferred medium–very high potency topical steroid, and document benefit for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum beneficiary age asked on form

≥1required topical steroid trial

specialistspecialist prescriber

requireddocumentation

Coverage Criteria

Initial and continuation authorization criteria

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) for Prurigo Nodularis prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm beneficiary is ≥18, has Prurigo Nodularis, tried ≥1 preferred medium–very high potency topical steroid, and document benefit for continuation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial authorization: Beneficiary is 18 years of age or older.age >= 18

Documented on form item 1.

Initial authorization: Beneficiary has a diagnosis of Prurigo Nodularis.

Documented on form item 2.

Initial authorization: Beneficiary has tried and failed, or has a contraindication or intolerance to at least one preferred medium to very high potency topical steroid.>= 1 preferred topical steroid trial

Documented on form item 3.

Initial authorization: Dupixent is prescribed by or in consultation with a dermatologist, allergist, or immunologist.

Documented on form item 4.

Continuation of therapy: While on Dupixent, beneficiary has had continued clinical benefit from baseline supported by medical records.

Form item 5 requests documentation of continued clinical benefit and medical records.

Provider Actions and Requirements

Prior Authorization

Prior authorization requirements

Prior authorization requests must confirm that the beneficiary has a diagnosis of Prurigo Nodularis, is 18 years of age or older, has tried and failed (or has a contraindication or intolerance to) at least one preferred medium to very high potency topical steroid, and that Dupixent is prescribed by or in consultation with a dermatologist, allergist, or immunologist.

Step Therapy

Topical steroid step

Before Dupixent will be approved, the beneficiary must have tried and failed, or have a contraindication or intolerance to, at least one preferred medium to very high potency topical steroid.

Form question: "Has the beneficiary tried and failed, or has contraindication, or intolerance to at least one preferred medium to very high potency topical steroid?"

Documentation Required

Required documentation

Include medical records documenting the beneficiary's current Prurigo Nodularis status and, for continuation requests, documentation of continued clinical benefit from baseline while on Dupixent; prescriber signature and date are required on the form.

Provide medical records showing current disease status and response to Dupixent.
Prescriber must sign and date the form (Prescriber Signature Mandatory).

Note

Form completion required

The prior authorization form must have completed beneficiary, prescriber, drug, and clinical information sections including beneficiary name/ID/DOB, prescriber NPI and contact information, drug name/strength/quantity and length of therapy, and the clinical questions about age, diagnosis, topical steroid trial, prescriber specialty, and continuation benefit.

Beneficiary: name, ID, date of birth, gender (chunk 0).
Prescriber: NPI and requester contact information (chunk 1).
Drug: name, strength, quantity per 30 days, length of therapy (chunk 2).
Clinical: age ≥18, diagnosis of Prurigo Nodularis, topical steroid trial, prescriber specialty, continuation benefit question (chunk 3).
Prescriber signature required (chunk 4).

Denial Risk

Denial triggers

The request may be denied if required documentation is absent or if there is no evidence of clinical benefit while on Dupixent.

Missing medical records documenting current Prurigo Nodularis status or lack of prescriber signature.
No documentation of continued clinical benefit from baseline while on Dupixent for continuation requests.

Background

Prurigo Nodularis is a chronic pruritic skin condition characterized by intensely itchy nodules. The prior authorization form frames Dupixent (dupilumab) as a targeted biologic therapy to be considered when topical measures are insufficient. The form requires confirmation of a diagnosis of Prurigo Nodularis and documents that the beneficiary is at least 18 years of age, has tried and failed (or has a contraindication or intolerance to) at least one preferred medium to very high potency topical steroid, and that Dupixent is prescribed by or in consultation with a dermatologist, allergist, or immunologist. For continuation, the form requires documentation that the beneficiary has had continued clinical benefit from baseline while on Dupixent, with supporting medical records.

Definitions / Continuation Criteria

Continuation of therapy — documentation of clinical benefit

Continuation question on formWhile on Dupixent, has the beneficiary had continued clinical benefit from baseline supported by medical records? (Yes/No)

Required supporting documentationPlease provide medical records documenting the beneficiary's current Prurigo Nodularis status and response to Dupixent treatment.

Scope of assessmentContinuation assessment applies to beneficiaries already receiving Dupixent — form requests answers to clinical items 1–5 for continuation.

Prescriber attestationPrescriber signature and date required on the form certifying accuracy of provided information.

Use in prior authorization decisionLack of documented continued clinical benefit may be a basis for denial of continued Dupixent therapy.

OpenPayer

Dupixent (dupilumab) for Prurigo Nodularis prior authorization

Coverage Criteria

Coding

Provider Actions and Requirements

Background

Definitions / Continuation Criteria