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dupilumab — Blue Cross Blue Shield of New Mexico

moderate-to-severe asthma

Initial criteria

  • Initial approval requires ALL of the following:
  • 1. Continuation of therapy: patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed; OR new therapy initiation criteria below apply.
  • For moderate-to-severe atopic dermatitis (AD):
  • - Patient has at least 10% body surface area involvement OR involvement of difficult-to-treat areas (hands, feet, face, neck, scalp, genitals/groin, skin folds) OR EASI ≥16 OR IGA ≥3; AND
  • - Has tried and had inadequate response to, intolerance, or contraindication to a medium-potency topical corticosteroid used ≥4 weeks; AND
  • - Has tried and had inadequate response to, intolerance, or contraindication to a topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) used ≥6 weeks; OR
  • - Medication history indicates use of another biologic immunomodulator approved for AD.
  • For moderate-to-severe asthma:
  • - Eosinophilic type: baseline eosinophil count ≥150 cells/µL, or FeNO ≥20 ppb, or sputum eosinophils ≥2% while on high-dose inhaled or daily oral corticosteroids OR oral corticosteroid-dependent type; AND
  • - History of uncontrolled asthma while on controller therapy as shown by ≥2 systemic steroid bursts in past 12 months, or serious exacerbations requiring hospitalization/mechanical ventilation/ER/urgent care within past 12 months, or worsening control when corticosteroids tapered, or FEV1 <80% predicted.
  • For chronic obstructive pulmonary disease (COPD):
  • - Diagnosis confirmed by spirometry: post-bronchodilator FEV1/FVC <0.7; AND
  • - Airflow obstruction post-bronchodilator FEV1 30–70% of predicted; AND
  • - Eosinophilic phenotype (baseline eosinophils ≥300 cells/µL); AND
  • - Symptoms of chronic bronchitis ≥3 months within past 12 months; AND
  • - Inadequately controlled COPD on inhaled maintenance therapy, as shown by ≥2 moderate exacerbations requiring systemic corticosteroids or ≥1 severe exacerbation requiring hospitalization/mechanical ventilation/ER/urgent care in past 12 months.
  • For chronic rhinosinusitis with nasal polyps (CRSwNP):
  • - At least two CRS symptoms (nasal discharge, nasal obstruction/congestion, loss of smell, facial pressure/pain); AND
  • - Symptoms ≥12 consecutive weeks; AND
  • - Diagnosis confirmed by rhinoscopy/endoscopy or CT sinuses; AND
  • - Tried and had inadequate response to, intolerance, or contraindication to ≥1 intranasal corticosteroid (e.g., fluticasone, mometasone, Sinuva) after ≥4 weeks.
  • For chronic spontaneous urticaria (CSU/CIU):
  • - ≥6 weeks of hives and itching; AND
  • - If medications that cause/worsen urticaria are used, documentation of evaluation of these agents is required.