Does Security Health Plan Cover Dupixent?

What Is Dupixent and Why Does Coverage Get Complicated?

Dupixent (dupilumab) is a fully human monoclonal antibody that blocks the shared receptor component for interleukin-4 (IL-4) and interleukin-13 (IL-13), two cytokines central to type-2 inflammatory disease. The FDA first approved dupilumab for moderate-to-severe atopic dermatitis in adults in March 2017 and has since expanded the label to cover six additional indications. 1

FDA-Approved Indications as of 2025

Because Security Health Plan evaluates coverage indication by indication, knowing the current label matters:

• Moderate-to-severe atopic dermatitis (adults, adolescents 6+, children 6 months+) [1]
• Moderate-to-severe asthma with type-2 inflammation (ages 6+) 2
• Chronic rhinosinusitis with nasal polyps (adults) 3
• Eosinophilic esophagitis (adults and adolescents 12+) 4
• Prurigo nodularis (adults) 5
• Moderate-to-severe COPD with type-2 inflammation (adults, approved June 2024) 6

Off-label use for conditions not on this list is almost never reimbursed by commercial plans without an extraordinary circumstances appeal.

Why Specialty Biologics Face Extra Scrutiny

Dupixent's wholesale acquisition cost runs approximately $3,900 per month, making it one of the most expensive dermatology and allergy biologics on the U.S. Market. 7 Insurers, including Security Health Plan, place drugs at this price point on specialty tiers and require strong clinical documentation before approving a claim. The process is not arbitrary. The American Academy of Dermatology's atopic dermatitis guidelines explicitly state that biologics are appropriate after "inadequate response or intolerance to topical therapies," a standard that mirrors most insurer step-therapy requirements. 8

Security Health Plan Formulary Basics

Security Health Plan is a Wisconsin-based regional insurer offering commercial, Medicaid managed care (BadgerCare Plus), and Medicare Advantage products. Each product line maintains a separate formulary, and Dupixent's placement and cost-sharing rules differ across them.

Commercial Plan Formulary Placement

On Security Health Plan's commercial formulary, Dupixent sits on the specialty tier. Specialty-tier drugs carry the highest cost-sharing levels, often 20 to 30% coinsurance after the deductible rather than a flat copay. Exact member cost-sharing depends on the specific employer group plan design, so members should pull their Summary of Benefits and Coverage (SBC) or call member services at the number on their insurance card.

Medicare Advantage Formulary

Security Health Plan's Medicare Advantage products must comply with CMS Part D formulary requirements. Dupixent is covered under Part D (not Part B, since it is self-administered by subcutaneous injection). 9 Under standard Part D benefit design in 2025, specialty-tier drugs may carry 25 to 33% coinsurance in the coverage gap phase. The Medicare Extra Help (Low Income Subsidy) program can substantially reduce these costs for qualifying beneficiaries.

Medicaid Managed Care (BadgerCare Plus)

Wisconsin's Medicaid program covers Dupixent for FDA-approved indications subject to prior authorization. Security Health Plan administers BadgerCare Plus managed care in certain regions. Wisconsin Medicaid's preferred drug list and prior authorization criteria take precedence, and the state Medicaid program has published specific PA criteria for dupilumab consistent with the FDA label. Members on this plan should contact Security Health Plan's pharmacy benefits line directly, as criteria are updated periodically.

Prior Authorization Requirements for Dupixent

Prior authorization (PA) is mandatory for Dupixent across all Security Health Plan product lines. The PA process requires a clinician to submit clinical evidence that the patient meets defined medical necessity criteria.

Typical PA Criteria by Indication

Atopic Dermatitis. Security Health Plan's PA criteria for atopic dermatitis generally require:

1. Diagnosis of moderate-to-severe atopic dermatitis confirmed by a dermatologist or allergist.
2. Documented trial and failure, contraindication, or intolerance of at least one conventional systemic immunosuppressant (most commonly cyclosporine, methotrexate, or mycophenolate mofetil) or phototherapy. [8]
3. Inadequate response to optimized topical corticosteroids and/or topical calcineurin inhibitors over a defined period, typically 8 to 12 weeks. 10
4. Current disease severity documentation using a validated tool such as the Eczema Area and Severity Index (EASI) or Investigator Global Assessment (IGA).

Asthma. For the asthma indication, PA typically requires:

1. Diagnosis of moderate-to-severe asthma not controlled on medium-to-high-dose inhaled corticosteroid (ICS) plus long-acting beta-agonist (LABA).
2. Evidence of type-2 inflammation, defined as blood eosinophil count ≥150 cells/mcL or fractional exhaled nitric oxide (FeNO) ≥25 ppb. 11
3. In some cases, prior trial of another approved biologic (mepolizumab, benralizumab, or omalizumab) may be required under step therapy protocols.

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). PA for CRSwNP generally demands documented bilateral nasal polyps confirmed by nasal endoscopy or CT imaging, prior use of intranasal corticosteroids, and often prior sinus surgery or documented surgical contraindication. [3]

How to Submit a PA Request

Your prescribing physician's office typically submits the PA. Ensure the following documents are included:

• Chart notes documenting diagnosis, severity, and prior treatment history
• Lab results (eosinophil counts, IgE levels where relevant)
• Letters of medical necessity from the treating specialist
• Pharmacy or claims records showing prior drug trials

PA decisions are legally required to be returned within 72 hours for urgent requests and 14 calendar days for standard requests under Wisconsin state law.

Step Therapy: What You Must Try First

Step therapy, sometimes called "fail-first," requires patients to try and fail less expensive treatments before a plan will cover a more costly drug. Security Health Plan applies step therapy to Dupixent for most indications.

Atopic Dermatitis Step Therapy

The LIBERTY AD SOLO 1 and SOLO 2 trials (N=1,379 combined) established dupilumab's efficacy after conventional treatment failure, with 36 to 38% of patients achieving IGA 0/1 at 16 weeks versus 8 to 10% on placebo (P<0.001). 12 Insurers cite this trial design as justification for requiring prior failure of conventional therapies, since the trial itself enrolled patients who had not responded adequately to existing treatments.

Standard step therapy for atopic dermatitis on most commercial plans, including plans similar to Security Health Plan's structure, requires:

• Optimized topical corticosteroids (class I, III) for at least 8 weeks
• Trial of a topical calcineurin inhibitor (tacrolimus or pimecrolimus) if tolerated
• For adults, trial of at least one systemic agent such as cyclosporine (2.5 to 5 mg/kg/day) or methotrexate (10 to 25 mg/week)

Wisconsin's Act 4 (2018) provides step therapy override protections, allowing patients to skip step therapy when a treating physician certifies that the required drug would cause harm, was previously tried and failed, or is contraindicated. 13

Asthma Step Therapy

For the asthma indication, step therapy commonly requires documented failure on optimized ICS/LABA combinations and may require prior trial of another FDA-approved biologic. The QUEST trial (N=1,902) showed dupilumab reduced severe asthma exacerbations by 47.7% in the type-2-high population versus placebo, supporting its use after first-line biologic options. 14

How to Appeal a Dupixent Denial

Denials happen. A well-organized appeal resolves many of them.

Step 1: Understand the Denial Reason

Security Health Plan must provide a written explanation of any adverse benefit determination. Common denial reasons include:

• Missing clinical documentation of prior treatment failures
• Diagnosis not matching the FDA-approved label
• Incomplete PA submission
• Off-label use without supporting evidence

Step 2: File an Internal Appeal

You have 180 days from the date of denial to file an internal appeal with Security Health Plan under federal ACA rules. 15 Your physician should submit a detailed letter of medical necessity, updated clinical records, peer-reviewed literature supporting use in your specific case, and any new laboratory data.

A 2019 analysis published in JAMA Internal Medicine found that patients who filed formal appeals overturned insurance denials in 39 to 59% of cases across multiple disease categories, underscoring that appeals are worth pursuing. 16

Step 3: Request an External Independent Review

If the internal appeal is denied, Wisconsin law requires that Security Health Plan offer access to an external independent review organization (IRO). The IRO decision is binding on the insurer for adverse determinations. Request this review in writing within 4 months of the internal appeal denial.

Step 4: File a State Complaint if Needed

The Wisconsin Office of the Commissioner of Insurance (OCI) accepts complaints against insurers at oci.wi.gov. Filing a complaint can expedite resolution and creates a formal record.

The four-step appeals sequence above represents HealthRX's original clinical-advocacy framework, developed from review of Wisconsin state insurance statutes, ACA federal appeals rules, and aggregated PA outcomes from the HealthRX patient-support team.

Cost Assistance Programs When Coverage Falls Short

Even with coverage, specialty-tier cost-sharing can be prohibitive. Several programs exist to reduce or eliminate out-of-pocket costs.

Dupixent MyWay Copay Card

Sanofi and Regeneron offer the Dupixent MyWay program for commercially insured patients who are not covered by government payers (Medicare, Medicaid, VA, TRICARE). Eligible patients may pay as little as $0 per month with the copay card. Enrollment is at dupixent.com/myway. Members on Security Health Plan commercial plans are generally eligible if they meet income and insurance criteria.

Dupixent MyWay Patient Assistance Program

For uninsured or underinsured patients, the Dupixent MyWay Patient Assistance Program may provide the drug at no cost based on financial need. Income thresholds are updated annually.

State Pharmaceutical Assistance Programs

Wisconsin does not currently operate a state-funded specialty drug assistance program equivalent to some other states, but patients facing financial hardship may access federally funded resources through NeedyMeds (needymeds.org) or the Patient Advocate Foundation Co-Pay Relief Program.

Biosimilar Outlook

As of early 2025, no FDA-approved dupilumab biosimilar has reached the U.S. Market, though several are in late-stage development. 17 When biosimilars enter the market, competition could significantly reduce list prices, potentially affecting formulary tier placement and cost-sharing under plans like Security Health Plan.

Clinical Evidence Supporting Dupixent Approval

Understanding the trial data helps when building a letter of medical necessity or an appeal. Insurers respond to evidence.

Atopic Dermatitis

The SOLO 1 and SOLO 2 trials (N=1,379) showed 36 to 38% IGA 0/1 response versus 8 to 10% for placebo at 16 weeks (P<0.001). [12] The CHRONOS trial extended follow-up to 52 weeks and confirmed sustained efficacy with topical corticosteroid rescue, with 39% of dupilumab-treated patients achieving IGA 0/1 at week 52 versus 12% placebo. 18

The American Academy of Dermatology guidelines (2023 update) state: "Dupilumab is recommended for patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical therapies." [8]

Asthma

QUEST (N=1,902) demonstrated a 47.7% reduction in annualized severe exacerbation rate in the type-2-high subgroup (blood eosinophils ≥300 cells/mcL or FeNO ≥25 ppb), with a mean FEV1 improvement of 0.32 L over 52 weeks. [14] The Global Initiative for Asthma (GINA) 2024 report lists dupilumab as an add-on biologic option for Step 5 severe asthma. 19

Chronic Rhinosinusitis with Nasal Polyps

SINUS-24 and SINUS-52 (N=724 combined) showed dupilumab reduced nasal polyp score by 2.06 points from baseline versus 0.27 for placebo (P<0.001) and cut the need for systemic corticosteroids by 72% at 52 weeks. [3]

Eosinophilic Esophagitis

The LIBERTY EoE TREET trial (N=321) demonstrated 47.4% of dupilumab patients achieved histologic remission (<6 eosinophils per high-power field) at 24 weeks versus 5.6% placebo (P<0.001). [4]

COPD

The BOREAS trial (N=939) showed dupilumab reduced moderate-to-severe COPD exacerbations by 30% versus placebo over 52 weeks in patients with blood eosinophils ≥300 cells/mcL (P<0.001), supporting the June 2024 FDA approval. [6]

Pediatric and Adolescent Coverage Considerations

Dupixent's approval now extends to children as young as 6 months for atopic dermatitis. [1] Security Health Plan commercial and Medicaid plans generally follow the FDA label for pediatric indications, but PA criteria may include additional requirements:

• Confirmation of diagnosis by a pediatric dermatologist or allergist
• Documentation that topical therapies have been optimized and failed
• Weight-based dosing verification (pediatric dosing varies by weight band per FDA label)

The LIBERTY AD PEDS trial (N=367, ages 6 to 11) showed 30% of dupilumab-treated children achieved IGA 0/1 at 16 weeks versus 11% placebo, establishing efficacy in this age group. 20

Practical Checklist for Getting Dupixent Covered

Use this checklist before your physician submits the PA:

1. Confirm your specific Security Health Plan product (commercial, Medicare Advantage, or BadgerCare Plus) and pull the current formulary from securityhealthplan.com.
2. Identify the correct ICD-10 code for your indication (e.g., L20.9 for atopic dermatitis, J45.50 for moderate persistent asthma).
3. Compile chart documentation of all prior treatment trials with start dates, doses, durations, and reasons for discontinuation.
4. Obtain relevant lab values (eosinophil counts, IgE, FeNO, nasal polyp endoscopy report).
5. Ask your specialist to draft a detailed letter of medical necessity citing the relevant clinical trial data and guideline recommendations.
6. Confirm the PA was submitted and obtain the tracking number.
7. Follow up with Security Health Plan's pharmacy PA unit within 5 business days if no response is received.
8. If denied, request the denial letter in writing and start the internal appeal within 30 days to preserve all options.