Ebglyss (lebrikizumab-lbkz) — Highmark

Atopic dermatitis (moderate-to-severe)

Initial criteria

age ≥ 12 years
for pediatric patients, weight ≥ 40 kg
diagnosis of atopic dermatitis (ICD-10: L20) that is moderate-to-severe, confirmed by dermatologist, allergist, or immunologist
AND one of the following:
1. Member has experienced therapeutic failure or intolerance to one of the following:
a. one generic topical corticosteroid
b. one generic topical calcineurin inhibitor (tacrolimus or pimecrolimus)
OR
2. Prescriber attests member has severe atopic dermatitis and topical therapy would not be advisable for maintenance therapy due to:
a. member incapable of applying topical therapies due to extent of body surface area involvement
b. topical therapies contraindicated due to severely damaged skin

prescriber attests the member has experienced positive clinical response to therapy

initial: up to 6 months; reauthorization: up to 12 months