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dupilumab — Blue Cross Blue Shield of Oklahoma

chronic rhinosinusitis with nasal polyps

Initial criteria

  • Agent eligible for continuation of therapy if patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed
  • OR new use: patient must meet indication-specific criteria
  • Atopic dermatitis (AD):
  • - Patient has moderate-to-severe AD AND either ≥ 10% body surface area involvement OR involvement of difficult-to-treat sites (hands, feet, face, neck, scalp, groin, folds) OR EASI ≥ 16 OR IGA ≥ 3
  • - AND patient has tried and had inadequate response, intolerance, or contraindication to at least a medium-potency topical corticosteroid (≥4-week trial)
  • - AND patient has tried and had inadequate response, intolerance, or contraindication to a topical calcineurin inhibitor (≥6-week trial)
  • Asthma:
  • - Diagnosis of moderate-to-severe asthma AND either eosinophilic type (baseline eosinophil count ≥ 150 cells/μL OR FeNO ≥ 20 ppb OR sputum eosinophils ≥ 2%) OR oral corticosteroid-dependent type
  • - AND history of uncontrolled asthma on control therapy documented by ≥ 2 steroid bursts in 12 months OR serious exacerbation requiring hospitalization/ER visit OR control deterioration when tapering corticosteroids OR baseline FEV1 < 80% predicted
  • COPD:
  • - Diagnosis confirmed by spirometry (post-bronchodilator FEV1/FVC < 0.7)
  • - FEV1 30–70% predicted
  • - Eosinophilic phenotype (baseline eosinophil count ≥ 300 cells/μL)
  • - Chronic bronchitis symptoms ≥ 3 months in past 12 months
  • - History of inadequately controlled COPD on maintenance therapy: ≥ 2 steroid-requiring moderate exacerbations or ≥ 1 severe requiring hospitalization/ER visit in past 12 months
  • Chronic rhinosinusitis with nasal polyps (CRSwNP):
  • - ≥ 2 of nasal discharge, obstruction, smell loss, or facial pain/pressure
  • - Symptoms ≥ 12 weeks
  • - Diagnosis confirmed by rhinoscopy/endoscopy or CT
  • - Tried and failed, intolerant, or contraindicated to at least 1 intranasal corticosteroid (≥4-week trial)
  • Chronic spontaneous urticaria (CSU):
  • - Hives and itching > 6 weeks
  • - If taking medications that cause or worsen urticaria, addressed appropriately