Subject: Specialty Quantity Limit Dupixent 1692-H P2023a
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. If the member’s plan
allows a quantity limit exception review for the requested
medication, coverage of an additional quantity may be provided
up to the exception limit with prior authorization.
II. COVERED QUANTITIES
|
Medication
|
Standard
Limit
|
Exception
Limit*
|
FDA-recommended dosing
|
|
Dupixent 200
mg/ 1.14 mL
pre-filled
syringe/pen
|
2 syringes
/pens per
28 days
|
2 syringes
/pens per
14 days
|
Atopic dermatitis:
• Adults and pediatrics 6 years to 17
years of age weighing ≥ 60 kg:
Initial dose of 600 mg (two 300 mg
injections), followed by 300 mg
every other week.
• Pediatrics 6 years to 17 years of
age:
º 30 to < 60 kg: Initial dose of 400
mg (two 200 mg injections),
followed by 200 mg every other
week.
º 15 to < 30 kg: Initial dose of 600
mg (two 300 mg injections),
followed by 300 mg every 4
weeks.
• Pediatrics 6 months to 5 years of
age:
º 15 to < 30 kg: 300 mg every 4
weeks
º 5 to < 15 kg: 200 mg every 4
weeks
Asthma:
• Adults and adolescents (12 years
and older):
º Initial dose of 400 mg (two 200
mg injections), followed by 200
mg every other week, or
º Initial dose of 600 mg (two 300
mg injections), followed by 300
mg every other week
º Patients with oral corticosteroid-
dependent asthma, or with co-
morbid moderate-to-severe atopic
dermatitis for which Dupixent is
indicated: initial dose of 600 mg
(two 300 mg injections) followed
by 300 mg every other week
• Pediatrics (6 to 11 years of age):
º ≥ 30 kg: 200 mg every other
week
º 15 to < 30 kg: 100 mg every
other week or 300 mg every
four weeks
º Patients with asthma and co-
morbid moderate-to-severe atopic
dermatitis, follow the
recommended dosage for atopic
dermatitis
Chronic rhinosinusitis with nasal
polyposis (CRSwNP) for adults:
• 300 mg every other week
• Adult patients with chronic
rhinosinusitis with nasal polyposis
and moderate-to-severe asthma for
which Dupixent is indicated: initial
dose of 600 mg (two 300 mg
injections) followed by 300 mg every
other week
Eosinophilic esophagitis:
• Adult and adolescents (12 years and
older), weighing ≥ 40 kg: 300 mg
every week
Prurigo Nodularis for adults:
• Initial dose of 600 mg (two 300 mg
injections), followed by 300 mg
every other week
|
|
Dupixent 300
mg/ 2 mL pre-
filled
syringe/pen
|
4 syringes
/pens per
28 days
|
N/A
|
|
Dupixent 100
mg/ 0.67 mL
pre-filled
syringe
|
2 syringes
per 28 days
|
N/A
|
* Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit
Quantity Exception Criteria for approval.
Place of Service:
Outpatient
The above policy is based on the following references:
- Dupixent [package insert]. Tarrytown, NY: Regeneron Pharmaceuticals, Inc.; October 2022.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
August 13, 2023
