Dupixent — Cigna

Asthma

Initial criteria

Patient is age ≥ 6 years; AND
Patient meets ONE of the following (a or b): a) Patient has a blood eosinophil level ≥ 150 cells per microliter within the previous 6 weeks; OR had a blood eosinophil level ≥ 150 cells per microliter prior to treatment with Dupixent or another monoclonal antibody therapy that may alter blood eosinophil levels; OR b) According to the prescriber, the patient has oral (systemic) corticosteroid-dependent asthma (≥ 5 mg oral prednisone or equivalent per day for ≥ 6 months); AND
Patient has received at least 3 consecutive months of combination therapy with BOTH: a) An inhaled corticosteroid; AND b) At least one additional asthma controller or maintenance medication; AND
Patient has uncontrolled asthma at baseline defined by ONE of the following: two or more exacerbations requiring systemic corticosteroids in the previous year; OR ≥ 1 hospitalization, emergency department visit, or urgent care visit in the previous year; OR FEV1 < 80% predicted; OR FEV1/FVC < 0.80; OR asthma worsens upon tapering of oral corticosteroids; AND
Medication is prescribed by or in consultation with an allergist, immunologist, or pulmonologist.

Patient has already received at least 6 months of therapy with Dupixent; AND
Patient continues to receive therapy with one inhaled corticosteroid or one inhaled corticosteroid-containing combination inhaler; AND
Patient has responded to therapy as determined by the prescriber (e.g., decreased exacerbations, decreased symptoms, reduced hospitalizations or oral corticosteroid use).

initial 6 months; reauth 1 year