Adbry (tralokinumab-ldrm) — Highmark

Initial criteria

• age ≥ 12 years
• Diagnosis of moderate-to-severe atopic dermatitis (ICD-10: L20) confirmed by a dermatologist, allergist, or immunologist
• Member has experienced therapeutic failure or intolerance to ONE of the following: ONE generic topical corticosteroid OR ONE generic topical calcineurin inhibitor (tacrolimus or pimecrolimus) OR the prescriber documents that member has severe atopic dermatitis and topical therapy would not be advisable for maintenance due to either (a) member incapable of applying topical therapies due to extent of body surface area involvement OR (b) topical therapies contraindicated due to severely damaged skin
• Requested quantity does not exceed the recommended dosing regimen per FDA label

Reauthorization criteria

• Prescriber attests that member has experienced positive clinical response to therapy
• If age ≥ 18 years, prescriber has assessed member for dose de-escalation AND either (1) Adbry requested at dosing interval of every 4 weeks OR (2) Member has not achieved clear or almost clear skin and dose de-escalation would not be appropriate OR (3) Every 4-week dosing interval would not be appropriate (e.g., weight above 100 kg)

Approval duration

Initial: 6 months; Reauthorization: 12 months (Delaware Commercial fully-insured and ACA members initial 12 months)