CurrentUnitedHealthcarePolicy N/A

Dupixent (dupilumab) prior authorization form for asthma

A prescriber-completed prior authorization / coverage request form for Dupixent for treatment of asthma, collecting beneficiary, prescriber, drug, and clinical information including age, eosinophil count, corticosteroid dependence, prior controller therapy, concomitant biologic use, and ongoing benefit for continuation.

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization form for asthma

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete the prior authorization form including beneficiary, prescriber, drug, and clinical information, provide eosinophil count and prior medication history, and sign/date the attestation.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Form for single drug (Dupixent)

4Key clinical thresholds

Coverage Summary

Coverage stance: covered with criteria — This is a prescriber-completed prior authorization/coverage request form for Dupixent (dupilumab) for treatment of asthma that collects beneficiary, prescriber, drug, and clinical information including age, pre-treatment eosinophil count, oral corticosteroid dependence, prior controller therapy, concomitant biologic use, and documentation of ongoing benefit for continuation to determine medical necessity.

Initial Therapy Criteria

Initial Authorization Criteria (implied from form fields)

Coverage considered when ALL of the following are provided:

ALL of the following

Age: Beneficiary is age 6 years of age or older>= 6 years
Eosinophil count: Pre-treatment serum eosinophil count of 150 cells/mcL or greater at screening (within the past six weeks prior to the request)>= 150 cells/mcL (within past 6 weeks)
Request asks to list eosinophil count and confirm within past 6 weeks
Oral corticosteroid dependence: Has oral corticosteroid dependent asthma with at least 1 month of daily oral corticosteroid use within the last 3 months>= 1 month within last 3 months
Yes/No field
Prior controller therapy: Inadequate control of asthma symptoms after a minimum of 3 months of compliant use within the past 6 months of inhaled corticosteroids plus a long-acting beta2 agonist (LABA)>= 3 months compliant use within past 6 months
Request asks to list prior medication tried
Acute use exclusion: Dupixent will NOT be used for relief of acute bronchospasm or status asthmaticus
Yes/No field
Concomitant biologic exclusion: Dupixent will NOT be used concurrently with another monoclonal antibody for asthma
Yes/No field

Key clinical thresholds

Minimum age>= 6 years

Pre-treatment eosinophil count>= 150 cells/mcL (within past 6 weeks)

Oral corticosteroid dependence duration>= 1 month of daily oral corticosteroid use within last 3 months

Inhaled controller trial duration>= 3 months compliant use within past 6 months of inhaled corticosteroid + LABA

Continuation Therapy Criteria

Continuation of Therapy Criteria

For continuation, ALL of the following must be addressed:

ALL of the following

Answer initial items: Answer questions 1-7 (same items as initial) for continuation requests
Medical records requirement: While on Dupixent, beneficiary has had continued clinical benefit from baseline supported by medical records
Prescriber must provide medical records documenting current asthma status and response to treatment
Prescriber attestation: Prescriber signature and date certifying accuracy of information
Signature is mandatory

Provider Actions / Prior Authorization Requirements

Prior Authorization

Complete prior authorization form

Complete and sign the Dupixent prior authorization form. Provide beneficiary, prescriber, drug, and clinical information sections, including the prescriber attestation with signature and date. Include the beneficiary's pre-treatment serum eosinophil count (list the value) and prior medication history (long-acting controller therapy tried).

Provide beneficiary demographic and ID information
Provide prescriber NPI and contact information
Complete drug name, strength, quantity, and length of therapy
List pre-treatment eosinophil count (value) and prior controller medication history
Sign and date the prescriber attestation

Documentation Required

Provide medical records for continuation

For continuation requests, submit medical records that document the beneficiary's current asthma status and demonstrate continued clinical benefit from baseline while on Dupixent. Ensure records correspond to the responses to the continuation questions on the form.

Medical records supporting current asthma status
Documentation of clinical benefit from baseline while on therapy

Denial Risk

Inadequate or missing criteria may result in denial

Missing or insufficient documentation for any required field may lead to denial of coverage. Required documented fields include: beneficiary age, pre-treatment eosinophil count with timing/value, oral corticosteroid dependence, prior controller therapy trial, whether Dupixent will be used with another monoclonal antibody, and the prescriber signature/date.

Beneficiary age (≥ 6 years)
Pre-treatment eosinophil count value and confirmation it was within the past 6 weeks
Oral corticosteroid dependence (≥1 month daily use within last 3 months)
Prior controller therapy trial (≥3 months compliant use of inhaled corticosteroid + LABA)
Whether Dupixent will be used concurrently with another monoclonal antibody
Prescriber signature and date

Background

This is a prescriber-facing prior authorization form for Dupixent intended to capture medical necessity for asthma treatment. The form requires completion of beneficiary and prescriber information and drug details, and collects key clinical data including: age (is beneficiary ≥ 6 years); pre-treatment serum eosinophil count (150 cells/mcL or greater, within the past six weeks) with a field to list the count; confirmation of oral corticosteroid dependent asthma (at least 1 month of daily oral corticosteroid use within the last 3 months); documentation of inadequate control after ≥ 3 months of compliant inhaled corticosteroid + LABA therapy with space to list prior long-term medication(s); whether Dupixent will be used for relief of acute bronchospasm/status asthmaticus; whether the beneficiary will receive concurrent monoclonal antibody therapy; and for continuation requests, documentation of continued clinical benefit from baseline supported by medical records. The prescriber must sign and date the attestation.

Pre-treatment serum eosinophil count: the eosinophil count obtained within the past six weeks prior to the request, with a criterion of ≥ 150 cells/mcL at screening.

Oral corticosteroid dependent asthma: use of daily oral corticosteroids for at least 1 month within the last 3 months.