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dupilumab — Blue Cross Blue Shield of Illinois

chronic obstructive pulmonary disease (COPD)

Initial criteria

  • Requested agent is eligible for continuation of therapy AND prescriber states patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed
  • OR if new start: BOTH of the following:
  • Diagnosis of moderate-to-severe atopic dermatitis (AD) AND BOTH of the following:
  • • ONE of: ≥10% body surface area involvement OR involvement of body sites difficult to treat with prolonged topical corticosteroid therapy (e.g., hands, feet, face, neck, scalp, genitals/groin, skin folds) OR Eczema Area and Severity Index (EASI) ≥16 OR Investigator Global Assessment (IGA) ≥3
  • • ONE of: Tried and had inadequate response to at least a medium-potency topical corticosteroid for ≥4 weeks OR intolerance/hypersensitivity to a medium-potency topical corticosteroid OR FDA-labeled contraindication to all medium-/high-/super-potency topical corticosteroids AND ONE of: Tried and had inadequate response to a topical calcineurin inhibitor for ≥6 weeks OR intolerance/hypersensitivity to a topical calcineurin inhibitor OR FDA-labeled contraindication to all topical calcineurin inhibitors
  • OR patient's medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for treatment of AD
  • OR Diagnosis of moderate-to-severe asthma AND BOTH of the following:
  • • ONE of: Eosinophilic type asthma (baseline blood eosinophils ≥150 cells/μL, FeNO ≥20 ppb, or sputum eosinophils ≥2%) OR oral corticosteroid dependent asthma
  • • History of uncontrolled asthma while on control therapy as demonstrated by: ≥2 systemic corticosteroid courses in past 12 months OR serious exacerbations requiring hospitalization/mechanical ventilation/ER or urgent care visit in past 12 months OR controlled asthma that worsens when corticosteroids are tapered OR baseline FEV1 <80% predicted
  • OR Diagnosis of COPD AND ALL of the following:
  • • Diagnosis confirmed by spirometry post-bronchodilator FEV1/FVC ratio <0.7
  • • Airflow obstruction defined by post-bronchodilator FEV1 30–70% predicted
  • • Eosinophilic phenotype with baseline blood eosinophils ≥300 cells/μL
  • • Symptoms of chronic bronchitis ≥3 months within past 12 months
  • • Inadequately controlled COPD on inhaled maintenance therapy as shown by ≥2 moderate exacerbations requiring systemic corticosteroids within past 12 months OR ≥1 severe COPD exacerbation requiring hospitalization/mechanical ventilation/ER or urgent care visit within past 12 months
  • OR Diagnosis of CRSwNP AND ALL of the following:
  • • ≥2 of: nasal discharge, nasal obstruction/congestion, loss/decreased sense of smell, facial pressure/pain
  • • Symptoms for ≥12 consecutive weeks
  • • Diagnosis confirmed by rhinoscopy/endoscopy or sinus CT
  • • Tried and had inadequate response to one intranasal corticosteroid for ≥4 weeks OR intolerance/hypersensitivity to intranasal corticosteroids OR FDA-labeled contraindication to all intranasal corticosteroids
  • OR Diagnosis of CSU (CIU) AND ALL of the following:
  • • >6 weeks of hives and itching
  • • If currently treated with medications known to cause or worsen urticaria, evaluation for those causes completed