Dupixent — Cigna

Eosinophilic Esophagitis

Initial criteria

Patient is age ≥ 1 year; AND
Patient weighs ≥ 15 kg; AND
Diagnosis confirmed by endoscopic biopsy showing ≥15 intraepithelial eosinophils per high-power field; AND
Patient does not have a secondary cause of eosinophilic esophagitis; AND
Patient has received at least 8 weeks of therapy with a proton pump inhibitor; AND
Patient meets ONE of the following (a or b):
a) Tried dietary modifications to manage eosinophilic esophagitis; OR
b) Provider determined patient is not an appropriate candidate for dietary modifications; AND
Medication prescribed by or in consultation with an allergist or gastroenterologist.

Patient has already received at least 6 months of therapy with Dupixent; AND
Patient has experienced a beneficial clinical response, defined by ONE of the following (a, b, or c):
a) Reduced intraepithelial eosinophil count; OR
b) Decreased dysphagia/pain upon swallowing; OR
c) Reduced frequency or severity of food impaction.

initial 6 months; reauth 1 year