How To Get Dupixent Covered By Insurance

Chronic health conditions like severe eczema, asthma, or chronic rhinosinusitis with nasal polyps can be life-altering.

Dupixent (dupilumab) has become a beacon of hope for patients who suffer from these chronic conditions. Its high cost, averaging thousands of dollars per dose, doesn’t help, making insurance coverage necessary for almost everyone.

You might be overwhelmed with the process of getting Dupixent covered by insurance. The healthcare system is often confusing, full of complicated requirements and frustrating denials.

This article will give you a detailed guide on getting Dupixent covered by insurance and help you take charge of your health confidently.

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What is Dupixent?

Dupixent is a biological medicine developed for the treatment of chronic inflammatory diseases by targeting critical immune pathways.

Unlike most therapies that are symptom-focused, Dupixent directly targets inflammation and helps patients whose diseases are not optimally controlled by current therapies.

Read: Why Does Dupixent Hurt So Much?

How Dupixent Works?

Dupixent is a monoclonal antibody that inhibits two proteins crucial to the inflammatory response of the immune system: interleukin-4 (IL-4) and interleukin-13 (IL-13).

These proteins play a role in conditions such as eczema, asthma, and chronic rhinosinusitis, promoting excessive immune activity and leading to symptoms such as inflammation, itching, and constriction of the airway. Through its action on IL-4 and IL-13, Dupixent returns balance to the immune system.

Why Dupixent is so Expensive?

Dupixent is a class of biologics with an average cost of $3,000 per injection; annual spending will be between $37,000 and $75,000 for most, depending on the dosing frequency.

Dupixent is among those expensive biological drugs because of the complicated nature of its manufacturing process, the high-cost research done before its development, and targeted drug interventions on specific pathways of the immune system.

Without insurance, most patients cannot afford these costs; hence, obtaining coverage is highly essential.

Read: Dupixent Pen Vs Syringe: What’s the Difference

Basics of Insurance for Specialty Medications

Types of Insurance Plans

Getting Dupixent approved is a step toward understanding your coverage. Coverage routes depend on your kind of insurance:

Private Insurance

This includes coverage obtained through employers or bought individually. Private plans tend to cover specialty medications but sometimes require prior authorization.

Medicare

Medicare includes federal insurance for people aged 65 and older and those with disabilities. Dupixent is generally included in Medicare Part D (prescription drug plans).

Medicaid

State-based insurance for low-income people and families. Dupixent coverage under Medicaid is state-dependent and may be subject to a medical necessity prior to authorization.

Specialty Drug Coverage

Dupixent is a specialty drug, and as such, it usually undergoes stricter approval, including:

Having prior authorization with proper emphasis on the need for the drug.
Getting Dupixent on insurance may require trying and failing other treatments prior to approval.
Specialty drugs may have huge out-of-pocket costs even when covered with insurance.

Get to know your plan’s formulary (list of covered medications) and requirements for Dupixent.

Read: Dupixent Before and After Pictures: Dupilumab for Eczema

How to Get Dupixent Covered by Insurance?

Step 1: Verify Dupixent Is on Your Plan’s Formulary

Begin by reviewing your insurance company’s formulary (a list of medications covered by your insurance).

If Dupixent is on the list, review the specific conditions for coverage, such as the requirements of prior authorization or step therapy.

If Dupixent is not on the formulary, you may need to file for a formulary exception request, allowing you to make an argument based on medical necessity.

Step 2: Collaborate with Your Doctor on Prior Authorization

Your doctor is the most important key to getting Dupixent covered with insurance. Most insurance companies require prior authorization before approving specialty medications. This involves your doctor submitting the following:

History of previous treatments with a history of failure of other medications.
Documentation of your condition, including your severity and symptoms.
Medical Necessity for the Use of Dupixent.

Request a copy for your records, then follow up with your insurer to be sure the prior authorization request is being processed.

Step 3: Provide Supporting Documentation for Medical Necessity

What medical necessity means to many insurers is extensive proof, including:

Physician’s notes that detail your diagnosis and treatment history.
Photos of affected areas- for eczema.
Blood tests confirm asthma through the provision of eosinophil levels.

The better your case, the more likely your insurer is to approve Dupixent.

Step 4: Appeal a Denial

If a claim is rejected, that does not mean one should lose hope. Though common, most of the denials can be overturned through appeals. Here are a few things you can do after your claim is rejected:

Read your denial letter carefully. Most of the time, the reason relates to incomplete documentation or failure to meet prior authorization requirements.
Contact your doctor to gather more proof, such as additional test results or second opinions, that will help build a stronger case in support of your appeal.
If the appeal is rejected, you may have the case reviewed by an independent review organization.

Read: Dupixent vs Cibinqo: Dupilumab Vs Abrocitinib for AD

Patient Assistance Programs

In cases where your insurance benefit has been denied, or your out-of-pocket expenses are still unaffordable, patient assistance programs can be beneficial in several ways.

Dupixent MyWay: This is Sanofi’s support program, providing co-pay assistance, insurance guidance, and reimbursement support.
Non-profit Organizations: Organizations, including the PAN Foundation and NeedyMeds, provide grants or discounts to patients to make expensive drugs accessible.

Commonly Asked Questions

What Can I Do if My Insurance Company Won’t Pay for Dupixent?

If your insurance company is unable to provide coverage for Dupixent, you have a few options

Formulary exception request.
Appeal for any other supporting documentation.
Contact Dupixent MyWay, among other non-profit organizations, for help.

Is Dupixent Coverage by Medicare and Medicaid?

Yes. Medicare Part D usually covers Dupixent, but this may vary depending on the plan offered. Medicaid coverage is different based on each state and requires a great deal of evidence about medical necessity most times.

Are there Co-Pay Assistance Programs for Dupixent?

Yes, Dupixent MyWay has co-pay cards and other forms of assistance for eligible patients.