Dupixent — Medical Mutual

Initial criteria

• Patient is age ≥ 6 months; AND
• Patient has either ≥ 10% body surface area involvement OR (moderate-to-severe hand/foot dermatitis AND age ≥ 12 years); AND
• Patient meets two of three: inadequate response or not a candidate for ≥ 3 months topical agents, systemic agents, or phototherapy; AND
• Prescribed by or in consultation with allergist, immunologist, or dermatologist

Reauthorization criteria

• Patient has received ≥ 4 months therapy; AND
• Patient has responded to therapy as determined by prescriber

Approval duration

4 months initial, 1 year reauth