Dupixent — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Diagnosis confirmed by serum tests (IIF and ELISA); AND
• Inadequate response to or unsuitable for oral corticosteroids; AND
• Prescribed by or in consultation with dermatologist

Reauthorization criteria

• Patient has received ≥ 6 months of therapy; AND
• Patient has experienced clinical response (decreased skin involvement, decreased blisters/erosions, decreased urticaria, decreased erythema, or reduced corticosteroid need)

Approval duration

6 months initial, 1 year reauth