CurrentUnitedHealthcarePolicy N/A

Dupixent (dupilumab) prior authorization for asthma

Form is used to request prior authorization for Dupixent (dupilumab) for treatment of asthma in beneficiaries and documents prescriber, beneficiary, drug, and clinical information required for coverage decisions. Affects prescribing providers and UnitedHealthcare prior authorization reviewers.

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization for asthma

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Dupixent prior authorization form with required clinical fields and attach medical records documenting current asthma status and treatment response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=6min age

>=150eosinophil threshold

≥3 moprior ICS+LABA

1 moOCS dependence window

Coverage Criteria for Dupixent (dupilumab) — Asthma

Authorization criteria (form-based)

Coverage is determined based on completion of the form documenting all of the following where applicable.

Form completion: Beneficiary identification (name, ID, date of birth, gender) and prescriber information (NPI, requester contact) are provided and the prescriber signature and date are present.signature required

Chunks 0-1 and 3

Drug information: Drug name, strength, quantity per 30 days, and length of therapy are specified on the form.

Chunk 2

Age criterion: Beneficiary is 6 years of age or older.>= 6 years

Policy Summary

PayerUnitedHealthcare

PolicyDupixent (dupilumab) prior authorization for asthma

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Dupixent prior authorization form with required clinical fields and attach medical records documenting current asthma status and treatment response.

SourceLink

On This Page

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Dupixent is not intended for immediate symptom relief. Specifically, Dupixent must not be used for the relief of acute bronchospasm or status asthmaticus. The prior authorization form explicitly asks whether Dupixent will be used for acute bronchospasm or status asthmaticus and requires a negative response for coverage consideration.

Concurrent use of two biologic therapies for asthma is not permitted. The form queries whether the beneficiary will receive dual therapy with another monoclonal antibody for the treatment of asthma; concurrent monoclonal antibody therapy for asthma is an exclusion.

For clarity in clinical review, the form requires documentation that Dupixent is being used as maintenance therapy rather than for emergency treatment. Providers must answer that Dupixent will not be used for acute bronchospasm or status asthmaticus and must attest that the beneficiary is not receiving another asthma monoclonal antibody concurrently.

When completing authorization requests, reviewers will use the negative responses to the acute-use and dual-biologic questions to determine that the request meets the policy’s exclusions; affirmation of either acute-use intent or concurrent biologic therapy may render the request noncompliant with the coverage criteria.

Drug and Laboratory Coding / Key Clinical Thresholds

Covered drug (requested)mixed

dupilumab (generic name)

Drug name field captures Dupixent; no billing codes listed in document

Pre-treatment eosinophil count

Threshold>= 150 cells/mcL

TimingScreening within the past 6 weeks prior to the request

DocumentationForm requires listing the measured eosinophil count on the request

Minimum prior controller therapy duration

Minimum durationMinimum of 3 months compliant use

Lookback periodWithin the past 6 months

Required medicationsInhaled corticosteroid (ICS) plus a long-acting beta2-agonist (LABA)

DocumentationForm asks to list medication(s) tried

Oral corticosteroid dependence window

DefinitionAt least 1 month of daily oral corticosteroid use within the last 3 months

Time windowUse must occur within the most recent 3-month period prior to the request

Form captureQuestion on form asks whether beneficiary has oral corticosteroid dependent asthma and to indicate Yes/No

Actions Required from Prescribers / Prior Authorization Submission

Prior Authorization

Prior Authorization Required

Prior authorization for Dupixent requires completion and submission of the Dupixent prior authorization request form with all required drug and clinical details.

Complete and submit the Dupixent request/prior authorization form for all initial and continuation requests.
Include drug name, strength, quantity per 30 days, and requested length of therapy.

Prior Authorization

Required Form Fields

The completed request form must include beneficiary identifying information and prescriber contact/NPI details so the request can be processed.

Beneficiary: last name, first name, beneficiary ID #, date of birth, gender.
Prescriber: prescribing provider NPI # and requester contact name/phone/extension.
Drug fields: drug name, strength, quantity per 30 days, and length of therapy (select/record days).

Step Therapy

Required Trial: ICS + LABA

Documentation demonstrating a required trial of therapy must be submitted for initial approvals; specifically, document at least 3 months of compliant use of an inhaled corticosteroid (ICS) plus a long-acting beta2-agonist (LABA) within the past 6 months.

List the ICS + LABA medication(s) tried and dates of use.
Evidence of at least 3 months compliant use within the past 6 months is required for coverage consideration.

Documentation Required

Medical Records Required for Continuation

For continuation (renewal) requests, the prescriber must provide medical records documenting the beneficiary's current asthma status and clinical response to Dupixent.

Answer continuation-specific questions on the form (questions 1–7) and indicate whether the beneficiary has had continued clinical benefit from baseline.
Attach relevant medical records that support ongoing benefit (e.g., symptom control, exacerbation reduction, reduction in oral corticosteroid use, objective measures).

Denial Risk

Documentation / Denial Risk

Failure to provide the required medical records or completed form fields — including prescriber NPI/contact, beneficiary identifiers, drug details, documentation of prior ICS+LABA trial, and evidence of response for continuation — may result in denial or non-approval of the request.

Incomplete forms or missing medical records for continuation requests are at risk for denial.
Ensure all required fields and attachments are included before submission to avoid processing delays.

OpenPayer

Dupixent (dupilumab) prior authorization for asthma

Coverage Criteria for Dupixent (dupilumab) — Asthma

Drug and Laboratory Coding / Key Clinical Thresholds

Actions Required from Prescribers / Prior Authorization Submission

Key Definitions and Thresholds

Background