Dupixent — Blue Cross Blue Shield of Kansas

Initial criteria

• 1. ONE of the following: A. Requested agent is eligible for continuation of therapy AND ONE of the following: 1. Patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR 2. Prescriber states patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR B. BOTH of the following: 1. ONE of the following: A. Patient has a diagnosis of moderate-to-severe atopic dermatitis (AD) AND BOTH of the following: 1. ONE of the following: A. Patient has ≥10% body surface area involvement OR B. Patient has involvement of difficult-to-treat areas (hands, feet, face, neck, scalp, genitals/groin, skin folds) OR C. Patient has Eczema Area and Severity Index (EASI) ≥16 OR D. Patient has Investigator Global Assessment (IGA) ≥3 AND 2. ONE of the following: A. BOTH of the following: 1. ONE of the following: A. Tried and had an inadequate response to at least a medium-potency topical corticosteroid used for ≥4 weeks OR B. Has intolerance or hypersensitivity to at least a medium-potency topical corticosteroid OR C. Has FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids AND 2. ONE of the following: A. Tried and had an inadequate response to a topical calcineurin inhibitor (e.g., Elidel/pimecrolimus, Protopic/tacrolimus) used for ≥6 weeks OR B. Has intolerance or hypersensitivity to a topical calcineurin inhibitor OR C. Has FDA labeled contraindication to ALL topical calcineurin inhibitors OR B. Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for AD OR B. Patient has a diagnosis of moderate-to-severe asthma AND BOTH of the following: 1. ONE of the following (criteria continue beyond excerpt)