UnitedHealthcare Dupixent Prior Auth Policy Update

Coverage Criteria by Indication

Initial Therapy — Initial authorization for moderate to severe chronic atopic dermatitis

Initial authorization for moderate to severe chronic atopic dermatitis

Atopic Dermatitis Initial: (1) Diagnosis of moderate to severe chronic atopic dermatitis; AND (2) History of failure, contraindication, or intolerance to topical therapies; AND (3) Patient is not receiving Dupixent in combination with either a biologic immunomodulator (e.g., Adbry [tralokinumab-ldrm]) or a Janus kinase inhibitor (e.g., Rinvoq [upadacitinib], Xeljanz/XR [tofacitinib], Opzelura [topical ruxolitinib], Cibinqo [abrocitinib]) for treatment of the same indication.

Combination agents listed include tralokinumab and JAK inhibitors (examples provided).

Continuation Therapy — Reauthorization for atopic dermatitis

Reauthorization for atopic dermatitis

Atopic Dermatitis Reauth: (1) Documentation of positive clinical response to Dupixent therapy; AND (2) Patient is not receiving Dupixent in combination with either a biologic immunomodulator (e.g., Adbry [tralokinumab-ldrm]) or a Janus kinase inhibitor (e.g., Rinvoq [upadacitinib], Xeljanz/XR [tofacitinib], Opzelura [topical ruxolitinib], Cibinqo [abrocitinib]) for treatment of the same indication.

Asthma — Initial authorization for moderate-to-severe asthma

Initial authorization for moderate-to-severe asthma

Asthma Initial: (1) Diagnosis of moderate-to-severe asthma; AND (2) Dupixent will be used in combination with maintenance inhaled therapy (e.g., Advair/AirDuo, Breo Ellipta, Symbicort, Trelegy Ellipta); AND (3) One of the following: patient has an eosinophilic phenotype OR patient is currently dependent on oral corticosteroids for the treatment of asthma; AND (4) Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication.

Examples of maintenance inhaled therapies and excluded biologics are listed.

Asthma Reauth: (1) Documentation of positive clinical response to Dupixent therapy; AND (2) Dupixent is being used in combination with maintenance therapy (e.g., Advair/AirDuo, Breo Ellipta, Symbicort, Trelegy Ellipta); AND (3) Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication.

CRSwNP — Initial authorization for chronic rhinosinusitis with nasal polyposis (CRSwNP)

Initial authorization for chronic rhinosinusitis with nasal polyposis (CRSwNP)

CRSwNP Initial: (1) Diagnosis of chronic rhinosinusitis with nasal polyposis (CRSwNP); AND (2) Patient will receive Dupixent as add-on maintenance therapy in combination with intranasal corticosteroids; AND (3) Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication.

CRSwNP Reauth: (1) Documentation of positive clinical response to Dupixent therapy; AND (2) Patient will continue to receive Dupixent as add-on maintenance therapy in combination with intranasal corticosteroids; AND (3) Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication.

Eosinophilic Esophagitis — Initial authorization for eosinophilic esophagitis (EoE)

Initial authorization for eosinophilic esophagitis (EoE)

EoE Initial: (1) Diagnosis of eosinophilic esophagitis; AND (2) Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication.

EoE Reauth: (1) Documentation of positive clinical response to Dupixent therapy; AND (2) Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication.

Prurigo Nodularis — Initial authorization for prurigo nodularis

Initial authorization for prurigo nodularis

PN Initial: (1) Diagnosis of prurigo nodularis; AND (2) Patient is not receiving Dupixent in combination with either a biologic immunomodulator (e.g., Adbry [tralokinumab-ldrm], Nemluvio [nemolizumab-ilto]) or a Janus kinase inhibitor (e.g., Rinvoq [upadacitinib], Xeljanz/XR [tofacitinib], Opzelura [topical ruxolitinib], Cibinqo [abrocitinib]) for treatment of the same indication.

Initial Therapy - Prurigo Nodularis — Initial Authorization for prurigo nodularis — Covered when ALL of the following are met

Initial Authorization for prurigo nodularis — Covered when ALL of the following are met

Prurigo nodularis initial

Diagnosis of prurigo nodularis
Concomitant therapy: Patient is not receiving Dupixent in combination with either a biologic immunomodulator (e.g., Adbry [tralokinumab-ldrm], Nemluvio [nemolizumab-ilto]) or a Janus kinase inhibitor (e.g., Rinvoq [upadacitinib], Xeljanz/XR [tofacitinib], Opzelura [topical ruxolitinib], Cibinqo [abrocitinib]) for the same indication

inv-08: Reauthorization - Prurigo Nodularis

Reauthorization for prurigo nodularis — Covered when ALL of the following are met

Prurigo nodularis reauthorization

Clinical response: Documentation of positive clinical response to Dupixent therapy
Concomitant therapy: Patient is not receiving Dupixent in combination with either a biologic immunomodulator (e.g., Adbry [tralokinumab-ldrm], Nemluvio [nemolizumab-ilto]) or a Janus kinase inhibitor (e.g., Rinvoq [upadacitinib], Xeljanz/XR [tofacitinib], Opzelura [topical ruxolitinib], Cibinqo [abrocitinib]) for the same indication

Initial Therapy - COPD — Initial Authorization for COPD — Covered when ALL of the following are met

Initial Authorization for COPD — Covered when ALL of the following are met

COPD initial

Diagnosis of COPD
Phenotype: Patient has an eosinophilic phenotype
Concomitant maintenance: Dupixent will be used in combination with maintenance therapy (e.g., Advair/AirDuo, Bevespi Aerosphere, Breo Ellipta, Symbicort, Trelegy Ellipta)
Concomitant therapy exclusion: Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication

Reauthorization - COPD — Reauthorization for COPD — Covered when ALL of the following are met

Reauthorization for COPD — Covered when ALL of the following are met

COPD reauthorization

Clinical response: Documentation of positive clinical response to Dupixent therapy
Concomitant maintenance: Dupixent is being used in combination with maintenance therapy (e.g., Advair/AirDuo, Bevespi Aerosphere, Breo Ellipta, Symbicort, Trelegy Ellipta)
Concomitant therapy exclusion: Patient is not receiving Dupixent in combination with anti-interleukin-5 therapy (e.g., Nucala, Cinqair, Fasenra), anti-IgE therapy (e.g., Xolair), or a TSLP inhibitor (e.g., Tezspire) for treatment of the same indication

Initial Therapy - Chronic Spontaneous Urticaria — Initial Authorization for chronic spontaneous urticaria — Covered when ALL of the following are met

Initial Authorization for chronic spontaneous urticaria — Covered when ALL of the following are met

Chronic spontaneous urticaria initial

Diagnosis of chronic spontaneous urticaria
Prior therapy: Patient remains symptomatic despite H1 antihistamine treatment (e.g., cetirizine, fexofenadine, loratadine)
Concomitant therapy: Patient is not receiving Dupixent in combination with Xolair (omalizumab) for treatment of the same indication

Reauthorization - Chronic Spontaneous Urticaria — Reauthorization for chronic spontaneous urticaria — Covered when ALL of the following are met

Reauthorization for chronic spontaneous urticaria — Covered when ALL of the following are met

Chronic spontaneous urticaria reauthorization

Clinical response: Documentation of positive clinical response to Dupixent therapy
Concomitant therapy: Patient is not receiving Dupixent in combination with Xolair (omalizumab) for treatment of the same indication

Initial Therapy - Bullous Pemphigoid — Initial Authorization for bullous pemphigoid — Covered when the following is met

Initial Authorization for bullous pemphigoid — Covered when the following is met

Bullous pemphigoid initial

Diagnosis of bullous pemphigoid

Reauthorization - Bullous Pemphigoid — Reauthorization for bullous pemphigoid — Covered when the following is met

Reauthorization for bullous pemphigoid — Covered when the following is met

Bullous pemphigoid reauthorization

Clinical response: Documentation of positive clinical response to Dupixent therapy

Dupixent is not indicated for the relief of acute bronchospasm or status asthmaticus, and it is not indicated for other forms of urticaria. Requests for Dupixent to treat acute bronchospasm, status asthmaticus, or non‑chronic spontaneous urticaria subtypes do not meet coverage criteria.

Dupixent must not be used in combination with other specified biologic immunomodulators, Janus kinase (JAK) inhibitors, anti‑IL‑5 agents, anti‑IgE agents, or TSLP inhibitors for the same indication. Examples of prohibited combinations include Dupixent with tralokinumab or nemolizumab, with JAK inhibitors such as upadacitinib, tofacitinib, ruxolitinib (topical), or abrocitinib, and with anti‑IL‑5 (e.g., mepolizumab, reslizumab, benralizumab), anti‑IgE (e.g., omalizumab/Xolair), or TSLP inhibitor (e.g., tezepelumab/Tezspire). Coverage may be denied if Dupixent is prescribed concurrently with any of these agents for the same clinical indication.

Initial Therapy Criteria (by indication)

inv-35: Initial Therapy — Initial authorization rules vary by indication; all require diagnosis and exclusion of concurrent use with specified other biologics or JAKs.

Initial authorization rules vary by indication; all require diagnosis and exclusion of concurrent use with specified other biologics or JAKs.

General Initial: Each indication requires a documented diagnosis per the labeled condition AND that the patient is not receiving Dupixent concurrently with specified biologic immunomodulators, anti-IL-5 agents, anti-IgE agents, TSLP inhibitors, or Janus kinase inhibitors for the same indication. Specific additional requirements per indication (e.g., prior topical therapy failure for atopic dermatitis; concomitant maintenance therapy for asthma and COPD; intranasal corticosteroids for CRSwNP; H1 antihistamine failure for chronic spontaneous urticaria) are required as listed per indication.

Combination therapy exclusions are applied per indication.

inv-36: Initial - Prurigo Nodularis — Prurigo nodularis initial authorization

Prurigo nodularis initial authorization

Prurigo nodularis initial: (1) Diagnosis of prurigo nodularis; AND (2) Patient is not receiving Dupixent in combination with either a biologic immunomodulator (e.g., Adbry, Nemluvio) or a Janus kinase inhibitor (e.g., Rinvoq, Xeljanz/XR, Opzelura, Cibinqo) for treatment of the same indication.

Reauthorization / Continuation Criteria

Continuation Therapy

Reauthorization / Continuation — Dupixent will be approved for continuation when ALL of the following are met:

ALL of the following

Documentation of positive clinical response to Dupixent therapy (provider must include objective and/or clinician-assessed measures of improvement since initiation of therapy).
Required for all labeled indications including atopic dermatitis, asthma, and eosinophilic esophagitis (EoE).
Provider action: Initial authorization must have been obtained for one of the following indications
- Atopic dermatitis — initial authorization documented with baseline disease severity (e.g., EASI, BSA, or Investigator Global Assessment) and prior therapies tried/failed or contraindicated.
- Asthma — initial authorization documented with baseline control status, exacerbation history, lung function (e.g., FEV1), and evidence of type 2 inflammation when required by the initial criteria.

Provider Actions, Prior Auth & Denial Risks

Prior Authorization

Atopic dermatitis initial: document diagnosis and prior topical therapy failure

For initial authorization for atopic dermatitis, document a diagnosis of moderate to severe chronic atopic dermatitis and a history of failure, contraindication, or intolerance to topical therapies; also confirm the patient is not receiving Dupixent in combination with listed biologic immunomodulators or JAK inhibitors for the same indication.

Diagnosis: moderate to severe chronic atopic dermatitis
Prior failure/contraindication/intolerance to topical therapies
No concurrent use with listed biologic immunomodulators (e.g., tralokinumab) or JAK inhibitors (e.g., upadacitinib, tofacitinib, ruxolitinib, abrocitinib)

Prior Authorization

Asthma initial: document diagnosis, maintenance therapy, phenotype/OCS dependence

For initial authorization for asthma, document a diagnosis of moderate-to-severe asthma and that Dupixent will be used in combination with maintenance inhaled therapy; indicate either an eosinophilic phenotype or current oral corticosteroid dependence, and confirm no concurrent use with anti-IL-5, anti-IgE, or TSLP inhibitors for the same indication.

Definitions & Limitations of Use

Limitation of Use — Dupixent

Limitation of use (as stated) Dupixent is not for the relief of acute bronchospasm or status asthmaticus.

Urticaria indication limitationDupixent is not indicated for other forms of urticaria.

Applicable labeled indications (context)Dupixent is indicated for multiple type 2 inflammatory conditions (e.g., atopic dermatitis, asthma with eosinophilic phenotype or OCS-dependence, CRSwNP, EoE, prurigo nodularis, COPD with eosinophilic phenotype, chronic spontaneous urticaria, bullous pemphigoid).

Background

Dupixent (dupilumab) is an interleukin‑4 receptor alpha antagonist approved to treat multiple type‑2 inflammatory conditions. Labeled indications addressed in this policy include moderate to severe chronic atopic dermatitis, moderate‑to‑severe asthma (eosinophilic phenotype or oral corticosteroid–dependent), chronic rhinosinusitis with nasal polyposis (CRSwNP), eosinophilic esophagitis (EoE), prurigo nodularis, selected cases of COPD with eosinophilic phenotype, chronic spontaneous urticaria (CSU), and bullous pemphigoid.

Step Therapy Requirements

Requirement	Details
Step-therapy prerequisite	History of failure, contraindication, or intolerance to topical therapies is required for initial authorization of Dupixent for moderate to severe chronic atopic dermatitis.
Diagnosis requirement	Diagnosis of moderate to severe chronic atopic dermatitis is required.
Concomitant therapy exclusion	Patient must not be receiving Dupixent in combination with a biologic immunomodulator (e.g., Adbry/tralokinumab) or a Janus kinase inhibitor (e.g., Rinvoq/upadacitinib, Xeljanz/tofacitinib, Opzelura/ruxolitinib, Cibinqo/abrocitinib) for the same indication.

Restriction type	Examples / Listed agents
Prohibition: biologic immunomodulators	Examples include Adbry (tralokinumab-ldrm) and Nemluvio (nemolizumab-ilto); concurrent use with these agents for the same indication is prohibited.
Prohibition: Janus kinase (JAK) inhibitors	Examples include Rinvoq (upadacitinib), Xeljanz/XR (tofacitinib), Opzelura (topical ruxolitinib), and Cibinqo (abrocitinib); concurrent use for the same indication is prohibited.
Prohibition: anti‑IL‑5 therapies	Examples include Nucala (mepolizumab), Cinqair (reslizumab), and Fasenra (benralizumab); concurrent use for the same indication is prohibited.
Prohibition: anti‑IgE therapy	Example: Xolair (omalizumab); concurrent use for the same indication is prohibited.
Prohibition: TSLP inhibitor	Example: Tezspire (tezepelumab); concurrent use for the same indication is prohibited.
Therapy-sequencing effect	These concurrent‑use prohibitions act as a sequencing restriction — Dupixent will not be approved if used with the listed biologics, anti‑IL‑5, anti‑IgE, TSLP inhibitors, or JAK inhibitors for the same indication.

Coding

Covered CPT CodesCPTCovered

No codes listed

Not covered CPT CodesCPTNot Covered

No codes listed

Experimental/Investigational CPT CodesCPTExperimental

No codes listed

Policy Revision History

2025-11-01policy_effective_dateLatest

Policy effective date updated to 2025-11-01 reflecting program-wide changes including added indications and standardized approval duration.

2025-06reference_update

Package insert reference updated to June 2025 in references section.

2025-01-01approval_duration_update

OpenPayer

Dupixent (dupilumab) prior authorization

Coverage Criteria by Indication

Initial Therapy Criteria (by indication)

Reauthorization / Continuation Criteria

Provider Actions, Prior Auth & Denial Risks

Definitions & Limitations of Use

Background

Step Therapy Requirements

Coding

Policy Revision History