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Dupixent (dupilumab) — Highmark

Asthma

Initial criteria

  • age ≥ 6 years
  • Diagnosis of moderate-to-severe asthma (ICD-10: J82.83, J45.4, J45.5)
  • Member has a history of ≥2 asthma exacerbations requiring oral or injectable corticosteroids in the previous 12 months OR ≥1 hospitalization for asthma in the previous 12 months
  • Eosinophilic phenotype with blood eosinophils ≥150 cells/mcL OR currently taking daily or alternate-day oral corticosteroids
  • Inadequate symptom control despite regular treatment with medium- or high-dose inhaled corticosteroids (ICS) and at least one additional controller (LABA, LTRA, or theophylline) with or without oral corticosteroids
  • Member will continue medium- or high-dose ICS and at least one additional controller (LABA, LTRA, or theophylline) with or without OCS while using Dupixent
  • Requested quantity does not exceed the FDA-recommended dosing regimen

Reauthorization criteria

  • Prescriber attests to any of the following: decreased rescue medication or oral corticosteroid use; decreased frequency of severe asthma exacerbations; increased pulmonary function from baseline (e.g., FEV1); or reduction in asthma-related symptoms (e.g., coughing, shortness of breath, wheezing, fatigue, sleep disturbance)