Dupixent — Medical Mutual

Initial criteria

• Patient is age ≥ 1 year and weighs ≥ 15 kg; AND
• Diagnosis confirmed by biopsy (≥ 15 eosinophils/HPF); AND
• No secondary cause of eosinophilic esophagitis; AND
• Received ≥ 8 weeks PPI; AND
• Has trialed topical (esophageal) corticosteroid for ≥ 8 weeks OR has adrenal insufficiency OR history of oral candidiasis; AND
• Has tried dietary modification OR provider determined not appropriate; AND
• Prescribed by or in consultation with allergist or gastroenterologist

Reauthorization criteria

• Patient has received ≥ 6 months Dupixent; AND
• Patient has response (reduced eosinophils, improved dysphagia/pain, reduced food impaction)

Approval duration

6 months initial, 1 year reauth