Dupixent — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has ≥ 20 nodular lesions on arms, legs, or trunk; AND
• Pruritus for ≥ 3 months; AND
• Condition not medication-induced or secondary cause managed; AND
• Patient did not respond or is not candidate for ≥ 3 months of topical therapy, systemic therapy, and/or phototherapy (two of three required); AND
• Prescribed by or in consultation with allergist, immunologist, or dermatologist

Reauthorization criteria

• Patient has received ≥ 6 months Dupixent; AND
• Patient has clinical response (reduced nodular lesion count, decreased pruritus, reduced lesion size)

Approval duration

6 months initial, 1 year reauth