Ebglyss (lebrikizumab-lbkz) — United Healthcare

moderate to severe chronic atopic dermatitis

Preferred products

Diagnosis of moderate to severe chronic atopic dermatitis
History of failure, contraindication, or intolerance to two of the following therapeutic classes of topical therapies (document drug, date of trial, and/or contraindication): (a) Medium, high, or very-high potency topical corticosteroid [e.g., Elocon (mometasone furoate), Synalar (fluocinolone acetonide), Lidex (fluocinonide)] (b) Topical calcineurin inhibitor [e.g., Elidel (pimecrolimus), Protopic (tacrolimus)] (c) Eucrisa (crisaborole)
Patient is not receiving Ebglyss in combination with either of the following: (a) Biologic immunomodulator [e.g., Adbry (tralokinumab-ldrm), Dupixent (dupilumab)] (b) Janus kinase inhibitor [e.g., Cibinqo (abrocitinib), Opzelura (topical ruxolitinib), Rinvoq (upadacitinib), Xeljanz/XR (tofacitinib)]
Prescribed by one of the following: (a) Dermatologist (b) Allergist (c) Immunologist

Documentation of positive clinical response to Ebglyss therapy
Patient is not receiving Ebglyss in combination with either of the following: (a) Biologic immunomodulator [e.g., Adbry (tralokinumab-ldrm), Dupixent (dupilumab)] (b) Janus kinase inhibitor [e.g., Cibinqo (abrocitinib), Opzelura (topical ruxolitinib), Rinvoq (upadacitinib), Xeljanz/XR (tofacitinib)]
Prescribed by one of the following: (a) Dermatologist (b) Allergist (c) Immunologist

12 months