Dupixent — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Blood eosinophil count ≥ 300 cells/µL (recent or prior to therapy); AND
• Patient has received ≥ 3 months of combination therapy with LABA, LAMA, ICS OR with LABA + LAMA if ICS contraindicated; AND
• Patient has signs/symptoms of chronic bronchitis ≥ 3 months in past 12 months; AND
• Patient has history of ≥ 2 COPD exacerbations needing corticosteroid/antibiotic in past 12 months (with ≥ 1 requiring corticosteroid and occurred during combo therapy) OR ≥ 1 COPD hospitalization in past 12 months (occurring during combo therapy); AND
• Prescribed by or in consultation with allergist, immunologist, or pulmonologist

Reauthorization criteria

• Patient has received ≥ 6 months Dupixent; AND
• Patient continues therapy with inhaled LABA and LAMA; AND
• Patient has beneficial clinical response (reduced exacerbations/symptoms, improved lung function, less hospital/ED visits)

Approval duration

6 months initial, 1 year reauth