dupilumab — Blue Cross Blue Shield of Montana

Initial criteria

• The patient has at least 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 EASI score ≥ 16 OR IGA score ≥ 3.
• The patient has tried and had inadequate response, intolerance, or contraindication to medium-, high-, or super-potency topical corticosteroids used in the treatment of AD.
• The patient has tried and had inadequate response, intolerance, or contraindication to a topical calcineurin inhibitor (e.g., Elidel/pimecrolimus, Protopic/tacrolimus) used in the treatment of AD.
• OR the patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of AD.