Ebglyss — Medical Mutual

Atopic Dermatitis

Initial criteria

Patient is ≥ 18 years of age OR patient is 12 to 17 years of age AND weighs ≥ 40 kg
Patient has atopic dermatitis involvement estimated to be ≥ 10% of the body surface area according to the prescriber
Patient meets two of the following three conditions: (a) Patient did not respond adequately to (or is not a candidate for) a 3-month minimum trial of topical agents (e.g., corticosteroids, calcineurin inhibitors, crisaborole); OR (b) Patient did not respond adequately to (or is not a candidate for) a 3-month minimum trial of at least one systemic agent (e.g., cyclosporine, azathioprine, methotrexate, mycophenolate mofetil, oral corticosteroids); OR (c) Patient did not respond adequately to (or is not a candidate for) a 3-month minimum trial of phototherapy (e.g., PUVA, UVB)
Medication is prescribed by or in consultation with an allergist, immunologist, or dermatologist

Patient has already received at least 4 months of therapy with Ebglyss
Patient has responded to therapy as determined by the prescriber (e.g., marked improvements in erythema, induration/papulation/edema, excoriations, lichenification; reduced pruritus; decreased requirement for other topical or systemic therapies; reduced body surface area affected with atopic dermatitis; or other observed responses)

initial 4 months; reauth 12 months