Dupixent (dupilumab) — Highmark

Atopic Dermatitis

Initial criteria

age ≥ 6 months
Diagnosis of moderate-to-severe atopic dermatitis (ICD-10: L20) confirmed by dermatologist, allergist, or immunologist
Member meets one of the following: (a) experienced therapeutic failure or intolerance to one generic topical corticosteroid OR one generic topical calcineurin inhibitor (tacrolimus or pimecrolimus); OR (b) has severe atopic dermatitis and topical therapy would not be advisable for maintenance therapy due to: (i) extent of body surface area involvement preventing application, OR (ii) contraindication due to severely damaged skin
Requested quantity does not exceed the FDA-recommended dosing regimen

Prescriber attests that the member has experienced positive clinical response to therapy