Dupixent — Medical Mutual

Initial criteria

• Patient is age ≥ 12 years; AND
• Diagnosis confirmed by exam/endoscopy/CT; AND
• Patient has ≥ 2 symptoms for ≥ 12 weeks (nasal congestion, obstruction, discharge, reduced smell); AND
• Patient has received ≥ 4 weeks of intranasal corticosteroid and will continue; AND
• Patient has either received ≥ 1 systemic corticosteroid course (≥ 5 days in past 2 years), OR contraindication to systemic corticosteroid, OR prior nasal polyp surgery; AND
• Prescribed by or in consultation with allergist, immunologist, or ENT specialist

Reauthorization criteria

• Patient has received ≥ 6 months Dupixent; AND
• Patient continues intranasal corticosteroid therapy; AND
• Patient responded to therapy (reduced polyp size, improved symptoms)

Approval duration

6 months initial, 1 year reauth