Adbry (tralokinumab-ldrm subcutaneous injection – Leo) — Cigna

Initial criteria

• Patient is age ≥ 12 years; AND
• Patient has atopic dermatitis involvement estimated to be ≥ 10% of the body surface area according to the prescriber; AND
• Patient meets ALL of the following (a, b, and c):
• a) Patient has tried at least one medium-, medium-high-, high-, and/or super-high-potency prescription topical corticosteroid; AND
• b) This topical corticosteroid was applied daily for at least 28 consecutive days; AND
• c) Inadequate efficacy was demonstrated with this topical corticosteroid therapy, according to the prescriber; AND
• Medication is prescribed by or in consultation with an allergist, immunologist, or dermatologist.

Reauthorization criteria

• Patient has already received at least 4 months of therapy with Adbry; AND
• Patient has responded to therapy as determined by the prescriber.
• Examples of a response to Adbry therapy include marked improvements in erythema, induration/papulation/edema, excoriations, and lichenification; reduced pruritus; decreased requirement for other topical or systemic therapies; reduced body surface area affected with atopic dermatitis; or other observed responses.

Approval duration

initial 4 months; reauth 1 year