Why do insurance companies deny Dupixent?

There are a few different reasons why insurance companies deny Dupixent (dupilumab) coverage. Patients might run into insurance coverage challenges ranging from formulary exclusions and prior authorization hurdles to stringent step therapy requirements. Below, we take a closer look at some common reasons insurances might deny coverage of Dupixent.

Formulary Restrictions

One reason Dupixent may not be covered is because it is not on an insurance plan’s drug formulary. A formulary is a list of medications that are covered by a health insurance plan. They are designed to help manage prescription drug costs, and encourage the use of cost-effective options.

Formularies often use a tiered system that categorizes medications based on cost. Lower tiers typically include generic drugs with lower copays, while higher tiers may include brand-name or specialty drugs like Dupixent. Higher tier drugs usually cost more than lower tier drugs.

Inadequate Documentation for Prior Authorizations

Another reason insurances may deny Dupixent coverage is not having enough information on documentation required for prior authorizations. A prior authorization is a process used by health insurance companies to determine if they will cover a prescribed medication. It requires your healthcare provider to obtain approval from the insurance company, and helps ensure the treatment is medically necessary.

Prior authorizations aim to manage healthcare costs and to make sure treatment is aligned with established medical guidelines. For Dupixent, denials frequently occur when providers do not include certain information required by the insurance company. This may include test results, such as:

• Eosinophil counts
• Fractional exhaled nitric oxide levels
• FEV1 values

Sometimes, insurance companies require step-therapy. This means patients need to try other treatments before insurance will cover Dupixent. If providers fail to document prior use and failure of first-line medications, it will not be covered. Insurances usually require information such as the name of the medications tried, dosage, duration of treatment, and side effects. It is important to include the reason treatment was stopped.

Specialist Prescriber Requirements

Some health plans restrict Dupixent prescriptions to specialists, such as pulmonologists, gastroenterologists, or dermatologists. This means if you get a prescription from a primary care provider, they may deny coverage. Contact your insurance plan to find out if they have requirements around prescribers of Dupixent.

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Contraindications and Safety Policies

Patients who have a documented allergy to dupilumab or any ingredients in it are not recommended to use Dupixent and its use in these patients is contraindicated. Insurance plans may deny coverage if a patient is known to have a contraindication to Dupixent, or if the use of it could be unsafe. For example, some insurance plans will not cover Dupixent if a patient is also taking certain other biologic medications at the same time.

Off-label Uses

While Dupixent holds FDA approvals for six indications, insurers routinely deny off-label uses. Dupixent is FDA approved to treat the following conditions:

• Atopic dermatitis
• Asthma
• Chronic rhinosinusitis with nasal polyps
• Eosinophilic esophagitis
• Prurigo nodularis
• Chronic obstructive pulmonary disease

If a prescriber writes a prescription for an off-label use, your insurance plan may deny coverage of Dupixent.

Is Dupixent covered by Medicare and Medicaid?

About 79% of patients with Medicare Part D pay up to $100 per month for Dupixent, and the rest pay $100 or more per month. For some patients with Medicare Part D, the amount will be more in the beginning of the year and changes later. If you have Medicare Part D, you may be eligible for the Social Security Administration Extra Help program. This program helps those with a low income pay for their medications.

Medicaid may cover Dupixent, but coverage varies by state and you might need to meet certain criteria. Check with your local Medicaid program to confirm coverage. Most Medicaid patients pay $4 to $9 per month for Dupixent.

This is not all the information you need to know about Dupixent (dupilumab) for safe and effective use and does not take the place of your doctor’s directions. Review the full product information and discuss this information and any questions you have with your doctor or other health care provider.