Nemluvio (nemolizumab-ilto subcutaneous injection – Galderma) — Cigna

Atopic dermatitis

Initial criteria

Patient is age ≥ 12 years; AND
According to the prescriber, the patient has atopic dermatitis involvement estimated to be ≥ 10% of the body surface area; 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) According to the prescriber, inadequate efficacy was demonstrated with this topical corticosteroid therapy; AND
Patient meets ONE of the following (a or b): a) For initial therapy, the medication will be used in combination with a topical corticosteroid and/or a topical calcineurin inhibitor; OR b) The patient’s atopic dermatitis has sufficiently improved with Nemluvio and topical therapy has been discontinued; AND
The medication is prescribed by or in consultation with an allergist, immunologist, or dermatologist.

Patient has already received at least 4 months of therapy with Nemluvio; AND
Patient has responded to therapy as determined by the prescriber (e.g., improvements in erythema, induration/papulation/edema, excoriations, lichenification; reduced pruritus; decreased requirement for other topical or systemic therapies; reduced body surface area affected; or other responses observed).

initial 4 months, reauth 1 year