Pharmacy Prior Authorization Criteria

Nemluvio (nemolizumab-ilto)

Indications for Prior Authorization

Nemluvio (nemolizumab-ilto)

• For diagnosis of Prurigo Nodularis (PN)
  Indicated for the treatment of adults with prurigo nodularis.

Criteria

Nemluvio

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Prurigo Nodularis (PN)

• Diagnosis of prurigo nodularis (PN)
AND
• Patient has at least 20 nodular lesions
AND
• Prescribed by or in consultation with one of the following:
• Allergist/Immunologist
• Dermatologist
AND
• Trial and failure, contraindication, or intolerance to one medium or higher potency topical corticosteroid [2, 3]
AND
• Trial and failure, contraindication, or intolerance to Dupixent (dupilumab)

Nemluvio

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Prurigo Nodularis (PN)

• Patient demonstrates a positive clinical response to therapy as evidenced by at least ONE of the following:
• Reduction in the number of nodular lesions from baseline
• Improvement in symptoms (e.g., pruritus, inflammation) from baseline

Nemluvio

Non Formulary

Length of Approval: 6 Month(s)
For diagnosis of Prurigo Nodularis (PN)

• Submission of medical records (e.g., chart notes) confirming a diagnosis of prurigo nodularis (PN)
AND
• Patient has at least 20 nodular lesions
AND
• Prescribed by or in consultation with one of the following:
• Allergist/Immunologist
• Dermatologist
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming a trial and failure, contraindication, or intolerance to one medium or higher potency topical corticosteroid [2, 3]
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming a trial and failure, contraindication, or intolerance to Dupixent (dupilumab)

P & T Revisions

2024-10-16, 2024-10-03

References

1. Nemluvio Prescribing Information. Galderma Laboratories, L.P. Dallas, TX. August 2024.
2. Williams KA, Huang AH, Belzberg M, et al. Prurigo nodularis: pathogenesis and management. J Am Acad Dermatol. 2020;83(6):1567-75.
3. Leis M, Fleming P, Lynde CW. Prurigo nodularis: review and emerging treatments. Skin Therapy Lett. 2021;26(3):5-8.
4. Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023;89(1):e1-e20.

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Revision History

• 2024-10-16: New program
• 2024-10-03: New program

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