Dupixent (dupilumab) — Highmark

Initial criteria

• diagnosis of eosinophilic esophagitis
• weight ≥ 15 kg
• for age 1–11 years: prescriber attests history of EoE signs or symptoms OR for age ≥12 years: prescriber attests ≥2 episodes of dysphagia per week
• esophageal eosinophil count ≥15 eos/hpf on biopsy
• therapeutic failure, contraindication, or intolerance to high-dose proton-pump inhibitor (PPI) therapy

Reauthorization criteria

• prescriber submits documentation of histological remission (<15 eos/hpf) on esophageal biopsy OR prescriber attests reduced severity or frequency of symptoms of esophageal dysfunction

Approval duration

initial up to 6 months; reauthorization up to 12 months