Dupixent — CareFirst (Caremark)

Initial criteria

• Member age ≥ 1 year and weight ≥ 15 kg
• Member is experiencing symptoms of esophageal dysfunction (e.g., dysphagia, food impaction, vomiting, abdominal pain, food refusal, failure to thrive)
• Diagnosis confirmed by esophageal biopsy characterized by ≥ 15 intraepithelial esophageal eosinophils per high power field
• Member has had an inadequate treatment response to either of the following: proton pump inhibitor OR swallowed topical corticosteroid therapies (e.g., budesonide, fluticasone [powder or suspension for inhalation]), unless contraindicated or not tolerated

Reauthorization criteria

• Member age ≥ 1 year and weight ≥ 15 kg
• Member has achieved or maintained a positive clinical response as evidenced by improvement in signs and symptoms of EoE (e.g., dysphagia, heartburn, chest pain, emesis)

Approval duration

Initial 6 months, Reauthorization 12 months