Summary
Already effective 2025-10-01: the initial and renewal criteria were updated for moderate-to-severe atopic dermatitis, moderate-to-severe asthma, COPD, chronic rhinosinusitis with nasal polyposis, eosinophilic esophagitis and prurigo nodularis, and the initial length of approval changed from 6 months to 12 months. Prior authorization is required, and the use of samples by an individual will not be considered current or stable therapy to satisfy policy requirements. Dupixent (dupilumab) will be obtained through a BCBSMS network DSP-pharmacy.
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What to do
Action · 7 steps
01Billing team: Get prior authorization before billing Dupixent, because prior authorization is required.
02Confirm the individual meets the initial criteria for the diagnosis being treated, and that the prescriber has assessed and documented baseline pruritus and other symptom severity for atopic dermatitis.
03Confirm the prescribed dosage is within the program quantity limit based on the FDA-approved labeled dosage.
04Do not document sample use as current or stable therapy.
05For renewals, the individual must have been previously approved through the BCBSMS prior authorization process.
06Medication trials and adherence are determined from pharmacy claims data over the preceding twelve months, and medical records from the provider that list previously prescribed medications will not be sufficient to show them.
07Initial approval lasts 12 months.
Codes mentioned
C9399J3590
Original notice
Dupixent (dupilumab)
bcbsms.com · Always check the source before changing claims.
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