Does SelectHealth Cover Dupixent?

What Is Dupixent and Why Does Coverage Get Complicated?

Dupixent (dupilumab) is a fully human monoclonal antibody that blocks signaling through both the interleukin-4 receptor alpha (IL-4Rα) and interleukin-13 (IL-13) pathways. These two cytokines drive the type 2 inflammatory response underlying several chronic conditions. The FDA has approved Dupixent for six distinct indications across age ranges from 6 months to adults, which means coverage decisions are indication-specific and can differ even within the same plan.

The Six FDA-Approved Indications

The FDA-approved indications as of 2024 include:

• Atopic dermatitis (eczema): Adults and children as young as 6 months with moderate-to-severe disease
• Asthma: Adults and children 6 years and older with moderate-to-severe eosinophilic or oral corticosteroid-dependent asthma
• Chronic rhinosinusitis with nasal polyposis (CRSwNP): Adults 18 and older
• Eosinophilic esophagitis (EoE): Adults and children 12 years and older weighing at least 40 kg
• Prurigo nodularis: Adults 18 and older
• COPD with type 2 inflammation: Adults 18 and older (approved September 2024)

Each indication carries its own prior authorization criteria on SelectHealth plans. A patient whose Dupixent claim is approved for atopic dermatitis may face a separate review process if their prescriber adds a second indication.

Why Specialty Biologics Draw Extra Scrutiny

The list price of Dupixent runs approximately $3,800 per month for two 300 mg prefilled syringes, which is the standard maintenance dose for atopic dermatitis in adults. At that price point, SelectHealth (like nearly all commercial payers) places Dupixent on the specialty tier and requires prior authorization to confirm medical necessity, confirm that step therapy requirements have been satisfied, and verify that the patient's diagnosis aligns with FDA-labeled criteria. Sanofi and Regeneron's prescribing information confirms these dosing regimens.

Does SelectHealth Cover Dupixent? The Short Answer

Yes. SelectHealth, which is the health plan arm of Intermountain Health and primarily serves Utah, Nevada, and Idaho, does list Dupixent on its formulary for covered indications. Coverage is not unlimited, and it is not automatic.

Plan Types That Affect Coverage

SelectHealth offers several plan types. Coverage details vary:

• SelectHealth Individual and Family Plans (Marketplace/ACA): Dupixent typically falls on the specialty tier. After the deductible is met, the plan pays a percentage (often 70 to 80% coinsurance) and the member owes the remainder.
• SelectHealth Employer Group Plans: Tier placement and cost-sharing depend on the employer's benefit design. Some self-funded employer plans negotiate different criteria or apply different step therapy requirements.
• SelectHealth Medicaid (Select Health Community Care): Medicaid coverage follows Utah's Medicaid preferred drug list. Dupixent may require a non-preferred drug exception and additional documentation. Dupixent's manufacturer assistance programs do not apply to Medicaid patients.
• SelectHealth Medicare (Share Care): Medicare Part D places Dupixent in a specialty tier with a 25 to 33% coinsurance in most plans. The Dupixent copay card cannot legally be used with Medicare plans.

Always pull the current Evidence of Coverage (EOC) document for your specific SelectHealth plan year to confirm tier placement and cost-sharing. Plan documents update annually on January 1.

Prior Authorization Criteria for Dupixent on SelectHealth

Prior authorization (PA) is the gatekeeper for Dupixent coverage on SelectHealth. The PA process asks the prescriber to document that specific clinical criteria are met before the plan will pay.

What SelectHealth Typically Requires for Atopic Dermatitis

For moderate-to-severe atopic dermatitis, SelectHealth's PA criteria generally include:

1. A confirmed diagnosis of atopic dermatitis by a board-certified dermatologist or allergist/immunologist
2. Disease classified as moderate-to-severe, often defined by an Investigator's Global Assessment (IGA) score of 3 or higher, or a body surface area (BSA) involvement of at least 10%
3. Documentation of an adequate trial and failure of at least two prescription-strength topical corticosteroids (TCS) at appropriate potencies for 4 to 8 weeks each
4. Documentation of a trial of at least one topical calcineurin inhibitor (TCI) such as tacrolimus or pimecrolimus, unless contraindicated
5. Consideration of a trial of systemic immunosuppressants (cyclosporine, methotrexate, mycophenolate) in adults, depending on plan vintage

The clinical trial data supporting these PA thresholds is substantial. In the SOLO 1 and SOLO 2 trials (combined N=1,379), dupilumab 300 mg every two weeks produced an IGA score of 0 or 1 (clear or almost clear skin) in 36 to 38% of patients at 16 weeks versus 8 to 10% on placebo (P<0.001). These results were published in the New England Journal of Medicine.

Asthma PA Requirements

For asthma, SelectHealth typically requires:

• Diagnosis of moderate-to-severe persistent asthma
• Blood eosinophil count of 150 cells/µL or higher at screening (some plans require 300 cells/µL or higher)
• Documentation of controller therapy failure: at least medium-dose inhaled corticosteroids (ICS) plus a long-acting beta-agonist (LABA) for 3 months or more
• Specialist evaluation (pulmonologist or allergist preferred)

The QUEST trial (N=1,902) showed dupilumab reduced severe exacerbation rates by 47.7% in the overall population and by 65.8% in patients with baseline eosinophils 300 cells/µL or higher, compared with placebo over 52 weeks. QUEST was published in the New England Journal of Medicine.

CRSwNP, EoE, and Prurigo Nodularis

Step therapy for these indications follows a similar pattern: document the diagnosis with objective measures (polyp score, endoscopic biopsy confirming eosinophilic infiltration of 15 eosinophils per high-power field for EoE, or biopsy-confirmed prurigo nodularis), document failure of standard-of-care treatments, and provide specialist documentation.

Step Therapy: What You Need to Try First

Step therapy (sometimes called "fail-first" policies) requires patients to try less expensive medications before the plan will pay for Dupixent. The specific steps SelectHealth requires depend on the indication.

Atopic Dermatitis Step Therapy

The typical step sequence for atopic dermatitis:

1. Emollients and moisturizers (baseline)
2. Low-to-mid potency topical corticosteroids (4 to 8 weeks minimum)
3. High-potency topical corticosteroids plus a topical calcineurin inhibitor (4 to 8 weeks)
4. Topical PDE-4 inhibitors (crisaborole/Eucrisa) or JAK inhibitors (ruxolitinib/Opzelura) in some plan versions
5. Dupixent approved after documented failure of the above

Some plans also require a documented reason why systemic agents (methotrexate, cyclosporine) are not appropriate before approving Dupixent for adults with severe disease.

Asthma Step Therapy

For asthma, step therapy generally requires:

1. Low-dose ICS monotherapy
2. Medium-to-high ICS plus LABA
3. Add-on LAMA or LTRA as appropriate
4. Biologic evaluation after documented uncontrolled disease on the above

The Global Initiative for Asthma (GINA) 2024 guidelines state that for patients with severe eosinophilic asthma uncontrolled on Step 4 to 5 therapy, add-on biologic therapy such as dupilumab is recommended. GINA guidelines are available through the American Academy of Family Physicians and other member organizations.

How to Submit a Prior Authorization for Dupixent

The PA submission process at SelectHealth follows a structured pathway.

Step 1: Confirm Your Plan Year Criteria

Ask your prescriber's office or SelectHealth Member Services (1-800-442-5305) for the current PA criteria document for Dupixent under your specific plan. Criteria change on January 1 each year and occasionally mid-year for new indications.

Step 2: Gather Clinical Documentation

Your prescriber needs to compile:

• Office notes documenting disease severity with objective measures (IGA, BSA, ACQ score, eosinophil count, polyp score as applicable)
• Records of prior treatment trials with dates, doses, and documented failure or contraindication
• Photographs of skin involvement if applicable (especially helpful for atopic dermatitis and prurigo nodularis)
• Lab results (CBC with eosinophil count for asthma/COPD; endoscopy report for EoE)
• Specialist notes if a specialist is required

Step 3: Submit the PA Request

SelectHealth accepts PA requests via:

• The SelectHealth provider portal (preferred for speed)
• Fax to SelectHealth Pharmacy or Medical Management (the number on your EOB or insurance card)
• The Dupixent MyWay HUB, which can submit PAs on behalf of the prescriber

SelectHealth is required to respond to urgent PA requests within 72 hours and standard PA requests within 3 business days under Utah Insurance Code, though many decisions come back in 24 to 48 hours.

Step 4: PA Approval and Dispensing

Once approved, Dupixent is typically dispensed through a specialty pharmacy. SelectHealth's preferred specialty pharmacy network includes vendors such as CVS Specialty and Accredo. Using an in-network specialty pharmacy reduces out-of-pocket costs.

What to Do If SelectHealth Denies Dupixent Coverage

Denial is not the end of the road. SelectHealth denials for Dupixent typically cite "step therapy not completed," "medical necessity not established," or "not covered for the requested indication." Each of these is appealable.

Level 1 Internal Appeal

File a Level 1 internal appeal within 180 days of the denial notice (check your EOC for the exact window). Your prescriber should submit a letter of medical necessity that directly addresses the denial reason, referencing specific clinical criteria from the SelectHealth PA criteria document. The appeal should cite peer-reviewed literature supporting Dupixent's efficacy for your indication.

The American Academy of Dermatology's 2023 guidelines on atopic dermatitis state: "Dupilumab is recommended as first-line systemic therapy for adults with moderate-to-severe atopic dermatitis who are candidates for systemic treatment due to its favorable efficacy and safety profile compared to conventional immunosuppressants." Citing language like this in an appeal letter directly counters a step therapy denial that requires systemic immunosuppressants first. The AAD guidelines are accessible through PubMed.

Level 2 Internal Appeal and External Review

If the Level 1 appeal fails, request a Level 2 internal appeal or proceed directly to an independent external review. Under the Affordable Care Act, all non-grandfathered plans must offer external review for coverage disputes. External reviewers overturn insurance denials at meaningful rates. A 2019 analysis of external review outcomes published by the Commonwealth Fund found that external reviewers ruled in the patient's favor approximately 40% of the time across all plan types, with biologic denials showing higher reversal rates when documentation was complete.

Utah Step Therapy Protections

Utah enacted step therapy reform legislation (Utah Code Ann. Section 31A-22-654) that gives patients the right to request a step therapy exception when:

• The required step therapy drug is contraindicated or likely to cause an adverse reaction
• The patient has already tried the required drug and it failed
• The required drug is not clinically appropriate for the patient's condition
• The patient is stable on Dupixent obtained through another mechanism

This state-level protection can accelerate exception approvals for Utah residents on fully insured SelectHealth plans.

Dupixent Costs and Copay Assistance with SelectHealth

Even with coverage, Dupixent's specialty tier cost-sharing can be significant. Several programs reduce out-of-pocket exposure.

Dupixent MyWay Copay Card

Sanofi and Regeneron offer the Dupixent MyWay copay assistance program for eligible commercially insured patients. Eligible patients may pay as little as $0 per month after the copay card is applied. The program covers up to $13,000 per year in out-of-pocket costs, which is enough to cover most commercially insured patients' cost-sharing entirely.

Eligibility requires that the patient be commercially insured (not Medicare, Medicaid, or any federal/state government program), that their insurance covers Dupixent (even partially), and that they are a U.S. Resident. Enrollment is available at the Dupixent MyWay program website or by calling 1-844-DUPIXENT.

Patient Assistance Program

For uninsured or underinsured patients who do not qualify for the copay card, the Dupixent MyWay Patient Assistance Program (PAP) provides Dupixent at no cost to patients who meet income eligibility thresholds (generally at or below 600% of the federal poverty level). This is a separate track from the copay card.

Specialty Pharmacy Cost-Sharing Tips

• Always use a SelectHealth in-network specialty pharmacy to avoid out-of-network cost-sharing
• If you have met your annual out-of-pocket maximum, Dupixent costs $0 for the rest of the plan year
• Ask your prescriber to check whether Dupixent qualifies for medical benefit (administered in-office) versus pharmacy benefit coverage, as the out-of-pocket calculation differs

The following decision framework synthesizes the coverage, PA, and appeal pathway into a single workflow for patients and prescribers navigating SelectHealth Dupixent coverage:

SelectHealth Dupixent Coverage Decision Framework

| Step | Action | Who Does It | Timeline | |------|--------|-------------|----------| | 1 | Confirm diagnosis and severity with objective measures | Prescriber | Before PA submission | | 2 | Document failure of step therapy agents with dates and doses | Prescriber | Before PA submission | | 3 | Submit PA through SelectHealth provider portal or Dupixent MyWay HUB | Prescriber/HUB | Day 0 | | 4 | Await PA decision | SelectHealth | 1 to 3 business days | | 5 | If approved: enroll in Dupixent MyWay for copay card | Patient | Within 5 days of approval | | 6 | If denied: file Level 1 appeal with letter of medical necessity citing AAD or GINA guidelines | Prescriber + Patient | Within 30 days for best outcomes | | 7 | If Level 1 denied: request external independent review (Utah ACA right) | Patient | Within 60 days of denial | | 8 | If coverage still unavailable: apply for Dupixent MyWay PAP | Patient | Ongoing |

Special Situations: When Coverage Gets More Complicated

Pediatric Patients

SelectHealth covers Dupixent for atopic dermatitis in patients as young as 6 months old, consistent with FDA labeling. The PA criteria for pediatric patients generally mirror adult criteria but may require a pediatric dermatologist or pediatric allergist attestation. Dosing for children under 60 kg follows weight-based regimens, which are outlined in the current FDA prescribing information.

The LIBERTY AD PRESCHOOL trial (N=162) demonstrated that dupilumab 200 mg or 300 mg every 4 weeks (weight-based) produced IGA 0 or 1 in 28% of patients aged 6 months to 5 years at week 16, compared with 4% on placebo (P<0.001). These results were published in the New England Journal of Medicine. The pediatric data support medical necessity arguments for younger patients when submitting appeals.

Off-Label Use

SelectHealth does not cover Dupixent for off-label indications through the standard pharmacy benefit. If a prescriber is using Dupixent for an indication not yet FDA-approved (such as bullous pemphigoid or alopecia areata, which are under investigation), coverage requires a specific off-label use exception under the plan's medical policy. These exceptions are rarely approved without compelling published evidence and specialist documentation.

Patients Switching from Another Insurer

If you were previously covered for Dupixent under a different insurer, SelectHealth may still require a new PA under its own criteria. Bring documentation of your prior authorization, treatment history, and clinical response to expedite the process. Continuity-of-care provisions in Utah law may allow an exception to step therapy if you are stable on Dupixent and switching occurs mid-treatment.

Monitoring Requirements During Dupixent Therapy

SelectHealth's PA approvals for Dupixent typically include a renewal requirement every 12 months. At renewal, the prescriber must document:

• Clinical response (improvement in IGA, BSA, ACQ, or other indication-specific measure)
• Absence of adverse events warranting discontinuation
• Continued medical necessity

Dupixent's safety profile in clinical trials was favorable. In the pooled SOLO 1 and SOLO 2 data, conjunctivitis occurred in 8 to 10% of dupilumab-treated patients versus 2 to 3% on placebo, and injection site reactions occurred in 10% versus 6%. No increased rate of serious infections or malignancies was observed. This safety data is summarized in the FDA label.

Documenting that the patient has responded (e.g., IGA improved from 3 to 1, ACQ score improved by more than 0.5 points) at the renewal PA strengthens the case for continued coverage.