Western Health Advantage
Dupixent (dupilumab)
Drugs for the Skin : Drugs for the Skin
  • Available through Specialty Pharmacy;
  • PA Required
  • Prior Authorization: Asthma (injectable), Asthma OCS Dependent:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Nasal Polyposis:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: Asthma (injectable), Asthma OCS Dependent:
    ST Multiple Generics

    Nasal Polyposis:
    ST Single Generic

  • Quantity Limit: 30 day supply per 1 fill(s).
  • Asthma (injectable):
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)
    # of exacerbations in prior year: >= 1
    History of corticosteroid use: >= 3 months
    Additional controller failure requirement: >= 1
    EOS levels required at baseline (cellsmcl): >= 150
    Diagnosis Type: Moderate to Severe
    Evidence of Asthma Indicators: 1 of FEV1 <= 80% predicted;FEV1/FVC < 0.80
    Patient Weight Required: No
    Must Be Compliant with Therapy: No
    Non-smoker or Will Begin Smoking Cessation Efforts: No
    Symptoms Are Not Adequately Controlled: Yes
    Exacerbation Requiring Treatment with Systemic Corticosteroid: Optional
    Use in Combination with Other Injectable Asthma Product: No
    Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: No
    IgE Level Required: No
    Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
    Submission of Medical Records Required: No
    Eosinophilic asthma phenotype: Yes
    Injectable ST Required: No

    Asthma OCS Dependent:
    Age Requirement: >= 6
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)

    Nasal Polyposis:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Allergist;Immunologist;Otolaryngologist (Ear, Nose, and Throat Specialist)
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)

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