Pharmacy Prior Authorization Criteria

Ebglyss (lebrikizumab-lbkz)

Indications for Prior Authorization

Ebglyss (lebrikizumab-lbkz)

• For diagnosis of Atopic Dermatitis (AD)
  Indicated for the treatment of adults and pediatric patients 12 years of age and older who weigh at least 40 kg with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Ebglyss can be used with or without topical corticosteroids.

Criteria

Ebglyss

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of moderate to severe atopic dermatitis
AND
• One of the following:
• Involvement of at least 10% body surface area (BSA)
• SCORing Atopic Dermatitis (SCORAD) index value of at least 25 [A]
AND
• Both of the following:
• Patient is 12 years of age or older
• Patient weighs at least 40 kg
AND
• Prescribed by or in consultation with one of the following:
• Dermatologist
• Allergist/Immunologist
AND
• Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to TWO of the following [2]:
• Medium or higher potency topical corticosteroid
• Pimecrolimus cream
• Tacrolimus ointment
• Eucrisa (crisaborole) ointment
AND
• Trial and failure, contraindication, or intolerance to TWO of the following:
• Adbry (tralokizumab-ldrm)
• Dupixent (dupilumab)
• Cibinqo (abrocitinib)
• Rinvoq (upadacitinib)

Ebglyss

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy as evidenced by at least ONE of the following [1-2]:
• Reduction in body surface area involvement from baseline
• Reduction in SCORing Atopic Dermatitis (SCORAD) index value from baseline [A]

P & T Revisions

2024-12-05, 2024-11-08, 2024-11-08

References

1. Ebglyss Prescribing Information. Eli Lilly and Co. Indianapolis, IN. September, 2024.
2. 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.
3. European Task Force on Atopic Dermatitis. Severity scoring of atopic dermatitis: the SCORAD index. Consensus report of the European Task Force on atopic dermatitis. Dermatology. 1993; 186:23-31.
4. Blauvelt A, de Bruin-Weller M, Gooderham M, et al. Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (CHRONOS): a 1-year, randomised, double-blinded, placebo-controlled, phase 3 trial. Lancet 2017; 389(10086)(suppl):2287-2303.
5. Oranje AP. Practical issues on interpretation of scoring atopic dermatitis: SCORAD index, objective SCORAD, patient-oriented SCORAD and three-item severity score. Curr Probl Dermatol. 2011; 41:149-55.

---

End Notes

1. The Scoring Atopic Dermatitis (SCORAD) index is a clinical tool for assessing the severity of atopic dermatitis lesions based on affected body area and intensity of plaque characteristics. [3, 4] The extent and severity of AD over the body area (A) and the severity of 6 specific symptoms (erythema, edema/papulation, excoriations, lichenification, oozing/crusts, and dryness) (B) are assessed and scored by the Investigator. Subjective assessment of itch and sleeplessness is scored by the patient (C). The SCORAD score is a combined score (A/5 + 7B/2 + C) with a maximum of 103. Higher scores indicate greater severity/worsened state. A score of 25 to 50 indicates moderate disease severity and greater than 50 indicates severe disease. [5]

---

Revision History

• 2024-12-05: Addition of new 250 mg/2mL prefilled syringe
• 2024-11-08: New program
• 2024-11-08: New program

---