Evaluating Dupilumab for Placement in a Value-Based Health Plan

Larry Hanover

Dupilumab is effective for atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyps, but a recent presentation noted the payer challenge in placing the biologic in an optimal tier.

In an ideal situation, a drug could be placed in separate tiers, by indication, within a single formulary list. Such indication-specific pricing, as it is known, has not been deemed practical in the United States.

A poster presented at the Academy of Managed Care Pharmacy 2021 examined the situation of dupilumab (Dupixent), which is approved for atopic dermatitis (AD), asthma, and chronic rhinosinusitis with nasal polyps (CRSwNP).

For all 3 conditions, dupilumab was more effective compared with placebo and is well tolerated, the authors said. “Due to its high cost and multiple indications, tier placement of dupilumab must take many factors into consideration,” they noted.

They assessed its clinical and economic value for formulary placement using the Value-Based Assessment Framework for Health Plan Implementation. The Real-World Evidence Assessments and Needs Guidance tool was used to standardize literature searches and quality ratings. The Institute for Clinical and Economic Review Evidence Rating Matrix was used to combined the assessment of quality and net health benefit for comparing treatments.

Dupilumab is a biologic that blocks the interleukin-4 (IL-4) and IL-13 mediated signaling pathways.

Ideally, dupilumab would be placed under specialty tier 1 for AD (>$100,000/quality-adjusted life year [QALY]); specialty tier 2 for asthma (>$300,000/QALY), and nonformulary for CRSwNP. Since the drug can be excluded with prior authorization criteria for CRSwNP, it was determined to fit under specialty tier 2.

Dupilumab would be considered nonformulary for CRSwNP because a cost-effectiveness study (CES) determined it is less effective at a higher cost compared with endoscopic sinus surgery (with a low certainty of evidence), according to the authors.

Prior authorization would be required for treatment failure under current standard of care treatments of AD or asthma, according to the authors. Notably, a lower rate of severe adverse events may be related to its profile in AD.

Duiplumab was found to have an incremental cost-effectiveness ratio of $101,830 for AD compared to usual care (moderate certainty). The ratio was $351,000 for asthma (moderate certainty).

Five studies were included for the AD indication: 1 CES, 1 comparative effectiveness study (COS), and 3 meta-analyses (MA). Five studies were used for asthma (1 CES, 4 MA). Two were used for CRSwNP (1 CES, 1 MA). Three MAs were included to assess safety.

According to the presentation, the higher cost and low incremental benefit compared with other treatments limits its value, placing it in a specialty tier 2.


Pan R, Parker, T, Panchal R, et al. Evaluating dupilumab using the value-based assessment framework for health plan implementation. Poster presented at: AMCP 2021 Virtual Conference | April 13-14, 2021; Salt Lake City, UT.