CurrentColorado Rocky Mountain Health PlansPolicy N/A

Cytokine and CAM Antagonists: IL-4/IL-13/IL-31 Inhibitors (Washington) Prior Authorization Form - Community Plan open_in_new

Prior authorization request form to document clinical criteria for use of IL-4/IL-13/IL-31 inhibitors (Cytokine and CAM Antagonists) across multiple indications (atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyposis, eosinophilic esophagitis, prurigo nodularis, COPD) for Washington (Apple Health) members. Collects patient, prescriber, diagnosis-specific severity, prior therapy trials, and continuation-of-therapy response documentation.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCytokine and CAM Antagonists: IL-4/IL-13/IL-31 Inhibitors (Washington) Prior Authorization Form - Community Plan open_in_new

Policy CodePolicy N/A

Change TypeForm / Operational

Effective Date

Next Review Date

Key ActionComplete the Washington prior authorization form, include chart notes, weight and prior therapy documentation, and fax to 866-940-7328; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

6Covered Indications in form

24+Minimum distinct prior-therapy thresholds listed

>=1Specialist prescriber preferred/required

Coverage summary

Prior authorization request form to document clinical criteria for use of IL-4/IL-13/IL-31 inhibitors across multiple indications for Washington Apple Health members. The form operationalizes coverage rules and collects required clinical data, including patient and prescriber information, indication-specific severity measures, phenotype markers, prior medication trials with durations, and objective evidence (e.g., endoscopy/biopsy, FEV1, BSA/IGA/EASI) to support medical necessity. Requests may be for initial or continuation of therapy; continuation requires documentation demonstrating disease stability or a positive clinical response as defined per indication. Coverage stance: covered_with_criteria.

Key numeric thresholds

Atopic dermatitis - BSA>= 10% involvement

Atopic dermatitis - EASI improvement>= 50% decrease from baseline

Atopic dermatitis - BSA reduction (continuation)>= 20% reduction from baseline

Prurigo nodularis - nodules>= 20 nodules for at least 3 months

Prurigo nodularis - WI-NRS>= 7

Nemolizumab prior dupilumab trialMinimum trial of 24 weeks

Asthma - eosinophilic phenotypeBlood eosinophils >= 150 cells/μL within last 12 months

COPD - eosinophil count>= 300 cells/µL within last 12 months

EoE - histologyPeak >= 15 eos/hpf (~60 eos/mm2) on endoscopic biopsy

Indication-specific initial and continuation criteria

General submission requirements

Request form requires completion of all fields and submission of chart notes and documentation; allow at least 24 hours for review.

ALL of the following

Complete entire prior authorization form and fax to 866-940-7328 or call 800-310-6826 for questions; include chart notes.
Provide patient weight (kg) and date taken; documentation of current weight must be provided.
Indicate if request is continuation of therapy and, if continuation, provide documentation demonstrating disease stability or positive clinical response.
Indicate if prescribed by or in consultation with a specialist (Allergist, Dermatologist, Gastroenterologist, Immunologist, Otolaryngologist, Pulmonologist, Other).
Indicate whether medication will be used in combination with another Cytokine and CAM medication.
If non-preferred agent requested, document trials of preferred Cytokine and CAM medications on Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated, including medication name and duration, OR explain why preferred products were not tried.
Chart notes are required with request; prescriber signature, specialty, and date required.

Atopic dermatitis - Initial and continuation criteria

Covered when ALL of the following applicable criteria are met and prior topical/systemic therapy trials documented unless contraindicated or clinically inappropriate:

ALL of the following

Disease severity (one or more)
- Body surface area (BSA) involvement of at least 10%>= 10% BSA
- Involvement of sensitive skin areas such as hands, feet, face, neck, genitalia, or intertriginous areas
- Baseline disease severity scale supporting moderate to severe chronic atopic dermatitis (e.g., IGA score ≥ 3; EASI; POEM)IGA ≥ 3

Asthma - Initial and continuation criteria

Covered when ALL applicable disease severity and phenotype criteria plus prior controller therapy documented; continuation requires documentation of response.

ALL of the following

Severity classification (select applicable: Moderate or Severe)
- Moderate
  - Daily symptoms
  - Nighttime awakenings >1x/week but not nightly
  - SABA use for symptom control occurs daily
  - Some limitation to normal activities

Chronic rhinosinusitis with nasal polyposis (CRSwNP) - Initial and continuation criteria

Covered when ALL applicable criteria are met including objective evidence, symptom severity, prior therapy trials, and continuation response.

ALL of the following

Diagnosis of bilateral sinonasal polyposis evidenced by endoscopy or CT (Yes/No)
Impaired health-related quality of life due to ongoing nasal congestion/blockage/obstruction with moderate to severe symptom severity (Yes/No)
Symptoms (one or more)
- Nasal discharge
- Facial pain or pressure

Eosinophilic esophagitis (EoE) - Initial and continuation criteria

Covered when ALL applicable diagnostic criteria and prior therapy trials are met and continuation response documented.

ALL of the following

Diagnostic features (one or more required)
- Symptoms consistent with EoE (e.g., dysphagia, food impaction, vomiting, chest/upper abdominal pain)
- Eosinophil-predominant inflammation with peak ≥15 eos/hpf (~60 eos/mm2) confirmed by endoscopic biopsypeak ≥15 eos/hpf (~60 eos/mm2)
- Underlying cause NOT considered to be other allergic conditions or other forms of esophageal eosinophilia
Persistent EoE symptoms during or following adequate trial of dietary restriction (e.g., empiric elimination diet) minimum trial of 2 months (Yes/No)

Prurigo nodularis - Initial and continuation criteria

Covered when ALL applicable severity and prior therapy failure criteria are met; for Nemolizumab-ilto specifically, prior trial of dupilumab is required.

ALL of the following

Disease severity (one or more)
- Presence of ≥20 nodules for at least 3 months>= 20 nodules for ≥3 months
- Worst-Itch Numeric Rating Scale (WI-NRS) score of at least 7WI-NRS ≥ 7
- Underlying cause not drug-induced or due to other medical conditions (e.g., dermatillomania)

COPD - Initial and continuation criteria

Covered when ALL applicable lung function, eosinophil count, and inhaled therapy criteria are met.

ALL of the following

Lung function: percent predicted FEV1 between 30-70% measured within the last 12 months (Yes/No)FEV1 30-70%
Dyspnea score ≥2 on the Medical Research Council dyspnea scale (Yes/No)MRC ≥ 2
Absolute blood eosinophil count ≥300 cells/µL within the last 12 months (Yes/No)>= 300 cells/µL
Current inhaled therapy

Required provider actions and documentation

Prior Authorization

Submit completed prior authorization form

Submit the completed prior authorization form and required chart notes via fax to 866-940-7328. Allow at least 24 hours for review. If you have questions, call 800-310-6826.

Fax: 866-940-7328
Phone: 800-310-6826

Documentation Required

Attach objective diagnostic and severity evidence per indication

Provide objective diagnostic and severity evidence specific to the indication being treated. Attach relevant reports, results, and measurements with the request.

Chronic rhinosinusitis with nasal polyposis: endoscopy or CT report documenting bilateral sinonasal polyposis
Eosinophilic esophagitis: endoscopic biopsy report showing peak eosinophils ≥15 eos/hpf (~60 eos/mm²)
Asthma/COPD: most recent percent predicted FEV1 and documentation of exacerbation history (eg, hospitalizations, ED visits, courses of systemic corticosteroids)
Atopic dermatitis: baseline BSA involvement, IGA score, EASI/POEM scores as available
Prurigo nodularis: documentation of nodules count and Worst-Itch Numeric Rating Scale (WI-NRS) score

Documentation Required

Document prior therapy trials and durations

Document prior therapy trials and durations for preferred agents or explain why preferred products were not tried. For non-preferred agent requests, include trials of Apple Health Preferred Drug List (AHPDL) agents with dates, durations, and outcomes (ineffective, intolerant, or contraindicated). Minimum trial durations must be provided where specified.

List each prior medication, dose, start and stop dates, and reason for discontinuation
Atopic dermatitis: topical corticosteroids, topical calcineurin inhibitors, topical PDE-4 inhibitors — minimum trial 28 days each
Chronic rhinosinusitis with nasal polyposis: intranasal corticosteroids — minimum trial 2 months; prior systemic corticosteroid use within 24 months
Eosinophilic esophagitis: PPI minimum trial 2 months; swallowed topical corticosteroids minimum 12 weeks
Prurigo nodularis: topical corticosteroids minimum 4 weeks; other topical agents/phototherapy/systemic agents per form minimums
If requesting a non-preferred biologic, document trials of preferred biologics or provide clinical rationale for not trying them

Documentation Required

Continuation requirements

For continuation requests, submit documentation demonstrating disease stability or a positive clinical response since initiation of therapy. Include objective measures or clinical outcomes showing improvement or maintenance.

Atopic dermatitis: ≥20% reduction in BSA from baseline, or achievement/maintenance of IGA 0–1, or ≥50% reduction in EASI from baseline
Asthma/COPD: reduced exacerbation frequency, improved or stabilized FEV1, decreased systemic corticosteroid requirements, fewer hospitalizations/ED visits
CRSwNP: improvement in nasal congestion/obstruction severity or reduction in nasal polyps
EoE: improvement in dysphagia/vomiting/abdominal pain and/or reduction in esophageal eosinophil count
Prurigo nodularis: reduced WI-NRS, fewer nodules, improved skin appearance or function

Denial Risk

Incomplete form or missing chart notes may delay or deny request

Incomplete forms or missing chart notes, objective test results, or required prior therapy documentation may delay or result in denial of the request. Ensure all required attachments and fields are completed before submission.

Chart notes and objective reports required with request
Missing documentation may delay review or lead to denial

Billing / coding guidance

No specific billing/coding provided on formmixed

No codes listed

Background and scope

This multi-indication prior authorization form documents that members meet indication-specific severity, phenotype, prior therapy trials, and response criteria for IL-4/IL-13/IL-31 inhibitors under Washington Apple Health. It captures patient weight, prescriber specialty, whether the request is a continuation, and requires chart notes and objective diagnostic evidence where applicable.

For each listed indication the form collects: indication-specific severity measures (e.g., BSA ≥ 10% or IGA ≥ 3 for atopic dermatitis; asthma severity classification and blood eosinophils ≥150 cells/µL for eosinophilic phenotype; bilateral sinonasal polyposis by endoscopy/CT for CRSwNP; EoE symptoms plus histology with peak ≥15 eos/hpf; prurigo nodularis nodules count and WI-NRS ≥7; COPD lung function and eosinophil thresholds), documentation of prior therapy trials with minimum trial durations (examples: topical and systemic corticosteroids, inhaled controller regimens, PPIs, swallowed topical steroids, intranasal corticosteroids, phototherapy, systemic immunosuppressants), and evidence of treatment response for continuation requests.

The form operationalizes coverage rules by requiring completion of all applicable fields, submission of chart notes and objective test results (e.g., endoscopy/biopsy, CT, FEV1, exacerbation history, BSA/IGA/EASI scores), listing prior preferred AHPDL agent trials or reasons they were not tried, and instructing submission to the specified fax/phone with at least 24 hours allowed for review. Incomplete forms or missing documentation may delay or lead to denial.

Quick scope facts

Covered indications in form6

Minimum distinct prior-therapy thresholds listed24+

Specialist prescriber preferred/required>=1 (e.g., Allergist, Dermatologist, Gastroenterologist, Immunologist, Otolaryngologist, Pulmonologist)

Definitions and thresholds

EoE histology threshold: peak value of ≥15 eosinophils per high-power field (~60 eosinophils/mm2) on endoscopic biopsy.

IGA: Investigator's Global Assessment; an IGA score of 3 or greater indicates moderate to severe disease for baseline assessments, and response for continuation is defined as IGA 0 or 1.

All thresholds (quick lookup)

Atopic dermatitis - BSA>= 10% involvement

Atopic dermatitis - IGA baselineIGA score of 3 or greater (baseline severity)

Atopic dermatitis - Prior topical therapy trialMinimum 28 days each (topical corticosteroids, calcineurin inhibitors, PDE-4 inhibitors)

Atopic dermatitis - Continuation response>= 20% BSA reduction OR IGA 0-1 OR >=50% EASI decrease

Asthma - Eosinophilic phenotypeBlood eosinophils >=150 cells/μL within last 12 months

Asthma - Exacerbation history>=1 exacerbation in prior year requiring oral corticosteroids >=3 days, or hospitalization/ED visit

CRSwNP - Intranasal corticosteroids trialMinimum trial of 2 months

CRSwNP - Recent systemic steroidsOral systemic corticosteroid therapy within the last 24 months

EoE - Diagnostic histologyPeak >=15 eos/hpf (~60 eos/mm2) on endoscopic biopsy

EoE - PPI trialPPI minimum trial of 2 months

EoE - Swallowed topical steroid trialMinimum trial of 12 weeks

Prurigo nodularis - Nodules & WI-NRS>=20 nodules for >=3 months; WI-NRS >=7

Prurigo nodularis - Topical steroid trialMinimum trial of 4 weeks

Prurigo nodularis - Additional prior therapiesCalcineurin/ vitamin D/phototherapy/systemic immunosuppressants minimum trials (3 weeks–1 month) as listed

Nemolizumab prior dupilumab trialMinimum trial of 24 weeks required before Nemolizumab-ilto

COPD - FEV1Percent predicted FEV1 between 30-70% within last 12 months

COPD - Eosinophils>= 300 cells/µL within last 12 months

COPD - Inhaled therapyMaximal inhaled therapy (ICS+LABA+LAMA) or LABA+LAMA if ICS contraindicated

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCytokine and CAM Antagonists: IL-4/IL-13/IL-31 Inhibitors (Washington) Prior Authorization Form - Community Plan open_in_new

Policy CodePolicy N/A

Change TypeForm / Operational

Effective Date

Next Review Date

Key ActionComplete the Washington prior authorization form, include chart notes, weight and prior therapy documentation, and fax to 866-940-7328; allow at least 24 hours for review.

SourceLink

On This Page

Functional impairment (one or more)

Activities of daily living impairment (ADLs)
Skin infections
Sleep disturbances
Other (specify)

Prior therapy failures (unless contraindicated or clinically inappropriate; minimum trial 28 days each)

Failure to topical corticosteroids of at least medium/moderate potency (examples: betamethasone, clobetasol, halobetasol, hydrocortisone, mometasone)>= 28 days
Failure to topical calcineurin inhibitors (examples: pimecrolimus cream, tacrolimus ointment)>= 28 days
Failure to topical PDE-4 inhibitors (example: crisaborole)>= 28 days
Or documentation that all are contraindicated or clinically inappropriate (explain)

Continuation-response documentation (one or more)

Reduction in body surface area involvement of at least 20% from baseline>= 20% reduction
Achieved or maintained clear or minimal disease from baseline (equivalent to IGA 0 or 1)IGA 0 or 1
Decrease in EASI score of at least 50% from baseline>= 50% decrease
Improvement in functional impairment (e.g., ADLs, infections, sleep)

FEV1 percent predicted >60% but <80%FEV1 >60% and <80%

Exacerbations requiring oral systemic corticosteroids more frequent/intense relative to mild asthma

Severe

Symptoms throughout the day
Nighttime awakenings often 7x/week
SABA use several times per day
Extremely limited normal activities
FEV1 percent predicted <60%FEV1 <60%
Exacerbations requiring oral systemic corticosteroids more frequent/intense relative to moderate asthma

If eosinophilic phenotype: blood eosinophils ≥150 cells/μL within last 12 months (Yes/No)>= 150 cells/μL

History of one or more exacerbations in prior year requiring daily oral corticosteroids for ≥3 days, or hospitalization or ED visit (in addition to regular maintenance therapy) (Yes/No)

Is patient dependent on oral corticosteroids for asthma control? (Yes/No)

Concomitant controller therapy (one or more)

Maximally tolerated ICS/LABA combination product (e.g., Advair, Airduo, Breo, Dulera, Symbicort)
Medium- to high-dose or maximally tolerated ICS with an additional asthma controller (e.g., LABA, LAMA, leukotriene receptor antagonist, theophylline)

Will asthma controller medications be continued with the requested drug unless contraindicated? (Yes/No)

Continuation of therapy requires documentation demonstrating disease stability or positive clinical response (e.g., reduced exacerbations, improved FEV1, reduced systemic corticosteroid requirements, reduced hospitalizations).

Reduction or loss of smell

Prior therapy failure/intolerance (one or more)

Intranasal corticosteroids (minimum trial of two months)minimum 2 months
Oral systemic corticosteroid therapy within the last 24 monthswithin 24 months

Maintenance intranasal corticosteroid should be continued with the requested drug unless contraindicated (Yes/No)

Continuation requires documentation of disease stability or positive clinical response (e.g., improvement in nasal congestion/obstruction severity, reduction in nasal polyps) (Yes/No)

Prior therapy failure/intolerance (at least one)

Proton pump inhibitors (PPIs) minimum trial of 2 monthsminimum 2 months
Swallowed topical corticosteroids (e.g., fluticasone, budesonide) minimum trial of 12 weeksminimum 12 weeks

Continuation requires documentation demonstrating disease stability or positive clinical response (e.g., improvement in dysphagia/vomiting/abdominal pain, reduction in eosinophils) (Yes/No)

Treatment with at least one medium to very high potency topical corticosteroid has been ineffective, not tolerated, or contraindicated (minimum trial of 4 weeks) (Yes/No)

Prior therapy failure/intolerance (one or more)

Topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) minimum trial of 3 weeksminimum 3 weeks
Topical vitamin D analogue (e.g., calcipotriene) minimum trial of 3 weeksminimum 3 weeks
Phototherapy (UVA or PUVB) minimum trial of 1 monthminimum 1 month
Systemic immunosuppressants (e.g., methotrexate or cyclosporine) minimum trial of 3 weeksminimum 3 weeks

For Nemolizumab-ilto (Nemluvio): prior treatment with dupilumab (Dupixent) has been ineffective, contraindicated, or not tolerated (minimum trial of 24 weeks) (Yes/No)minimum 24 weeks

Continuation requires documentation of disease stability or positive clinical response (e.g., reduced itching, improved skin appearance, reduction in nodules) (Yes/No)

Maximal inhaled therapy (ICS + LABA + LAMA)

Double maintenance therapy (LABA + LAMA) if ICS is contraindicated