This is an old revision of the document!
DUPIXENT (raised EOS count required for all)
1. Atopic derm (L20.9 or L20.89) -6 months or older with diagnosis of moderate-to-severe atopic dermatitis -documentation of disease burden (SCORAD, BSA %, EASI, POEM, etc) -inadequate response to potent topical corticosteroids and topical calcineurin inhibitors -inadequate response to oral systemic immunosuppressants or corticosteroids
2. Nasal Polyps (J33.9 or J33.0) -18 years or older with diagnosis of polyps supported by rhinoscopy, endoscopy or CT scan -inadequate response to intranasal and systemic corticosteroids -history of sino-nasal surgery *Depending on insurance, some PA's will ask if med is being prescribed with referral from/ in consultation with ENT provider* -BCBS Federal will only approve Dupixent for Nasal Polyps if ENT prescribing
3. Asthma (J45.40 or J45.50) -6 years or older with diagnosis of moderate-to-severe asthma of the following phenotypes:
-eosinophilic (EOs > 150 cells/uL within the past 6 months, or >300 cells/uL within the past year)
-oral corticosteroid dependent asthma requiring documentation of 3 months of patient trying asthma medications including a) high dose ICS, b) additional controller therapy (LABA or leukotriene modifier) and c) oral corticosteroids for at least 6 months (greater than or equal to 5mg per day of prednisone)
4. EoE (K20.0) -1 year or older & weighs over 15kg -diagnosis of EoE as supported by esophageal biopsy with >15 EOS/HPF -documentation of inadequate response to at least 8 weeks of high dose PPI and 6-8 weeks of oral swallowed steroids like budesonide or fluticasone propionate
5. Prurigo Nodularis (L28.1) -18 years or older & has failed trials of other therapies (antihistamines, xolair, etc)
6. Chronic spontaneous urticaria (L50.1, L50.8, L50.9) -12 years or older (and over 66lb) with diagnosis of CSU, documentation of inadequate response to H1 antihistamines *Not all insurance plans have released their criteria for approval for Dupixent to treat CSU*
7. COPD (J44) -18 years or older as add-on maintenance treatment for adults with inadequately controlled chronic obstructive pulmonary disease and a high number of blood eosinophils
PA: Dupixent required through pharmacy benefits insurance; not available to buy & bill through medical benefits at this time (can be costly for Medicare patients because of this)
link for DWM enrollment forms/ reapplying for PAP: www.dupixentmywayportal.com (code is 8443879370 aka DMW fax#)