Dupixent — Cigna

Initial criteria

• Patient is age ≥ 12 years; AND
• Chronic rhinosinusitis with nasal polyps confirmed by direct exam, endoscopy, or sinus CT scan; AND
• Patient has experienced ≥2 of the following symptoms for ≥6 months: nasal congestion, nasal obstruction, nasal discharge, and/or reduction/loss of smell; AND
• Patient has received ≥4 weeks of therapy with an intranasal corticosteroid AND will continue concomitantly; AND
• Patient meets ONE of the following (a, b, or c):
• a) Received ≥1 course of systemic corticosteroid for ≥5 days within previous 2 years; OR
• b) Has a contraindication to systemic corticosteroid therapy; OR
• c) Has had prior surgery for nasal polyps; AND
• Medication is prescribed by or in consultation with an allergist, immunologist, or otolaryngologist.

Reauthorization criteria

• Patient has already received at least 6 months of therapy with Dupixent; AND
• Patient continues to receive therapy with an intranasal corticosteroid; AND
• Patient has responded to therapy as determined by the prescriber (examples: reduced nasal polyp size, improved nasal congestion, reduced sinus opacification, improved sense of smell).

Approval duration

initial 6 months; reauth 1 year