Colorado Rocky Mountain Health Plans S1‑P Prior Auth | OpenPayer

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Colorado Rocky Mountain Health Plans S1‑P Prior Auth | OpenPayer

Alopecia areata — Initial and continuation criteria

Covered when ALL of the following are met

Alopecia areata criteria: (1) Current episode lasting more than 6 months; (2) SALT score ≥50% scalp hair loss (SALT >50%); (3) History of failure, contraindication, or intolerance to at least one of: high‑potency topical corticosteroids (minimum trial 6 weeks), intralesional corticosteroids (minimum trial 6 weeks), or systemic therapy (e.g., oral corticosteroids, methotrexate, cyclosporine) (minimum trial 6 weeks); (4) For continuation: documentation submitted demonstrating a positive clinical responseSALT >50%

See prior authorization form for checklist items and trial durations

Ankylosing spondylitis / Non-radiographic axial spondyloarthritis

Covered when ALL of the following are met

Axial spondyloarthritis criteria: (1) High disease activity demonstrated by BASDAI ≥4 OR ASDAS ≥2.1; (2) Trial of at least two different NSAIDs that were ineffective, contraindicated, or not tolerated (minimum trial of 4 weeks each); (3) Disease phenotype documented as axial disease or peripheral arthritis; (4) Trial of at least one non‑Cytokine and CAM DMARD that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months) unless clinically inappropriate; (5) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (e.g., decrease in BASDAI or ASDAS)

Atopic dermatitis — Initial and continuation criteria

Covered when ALL of the following are met

Atopic dermatitis criteria: (1) Disease severity as indicated by one or more: BSA ≥10% OR involvement of sensitive areas (hands, feet, face, neck, genitalia, intertriginous) OR severe chronic AD by validated score (e.g., IGA ≥3, EASI, POEM); (2) Functional impairment may include impaired ADLs, recurrent skin infections, or sleep disturbance; (3) History of failure, contraindication, or intolerance to topical therapies (medium/high potency topical corticosteroids, topical calcineurin inhibitors, topical PDE‑4 inhibitors) with minimum trials of 28 days each unless all are contraindicated/clinically inappropriate; (4) Prior trial of dupilumab (Dupixent) of minimum 16 weeks unless ineffective, contraindicated, or not tolerated; (5) For continuation: documentation submitted demonstrating disease stability or a positive clinical response defined by any of: ≥20% reduction in BSA, IGA 0/1 (clear or minimal), ≥50% decrease in EASI score, or improvement in functional impairment

Crohn's Disease — Initial and continuation criteria

Covered when ALL of the following are met

Crohn's Disease criteria: (1) Prior treatment with conventional therapies that were ineffective, contraindicated, or not tolerated, including short‑course oral corticosteroids for induction and an immunomodulatory agent (e.g., methotrexate, azathioprine, 6‑MP) with a minimum trial of 12 weeks; (2) Documentation of high‑risk disease features (examples: persistent symptoms despite conventional therapy, obstruction, abscess/phlegmon, stricture, fistula, prior resection, extensive bowel involvement, early age of onset, growth retardation, CDAI >450, Harvey‑Bradshaw index >7); (3) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (e.g., endoscopic improvement, steroid tapering/discontinuation, reduction in liquid stools, decreased abdominal pain, decreased CDAI or Harvey‑Bradshaw index)

Plaque Psoriasis — Initial and continuation criteria

Covered when ALL of the following are met

Plaque psoriasis criteria: (1) Ongoing disease for greater than 6 months; (2) Disease affecting at least 10% BSA OR involvement of face/ears/hands/feet/genitalia; (3) Baseline assessments submitted (e.g., BSA, PASI, PGA, itch NRS); (4) History of failure, contraindication, or intolerance to phototherapy (UVB or PUVA) with minimum trial of 12 weeks AND to at least one non‑Cytokine and CAM DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) with minimum trial of 12 weeks; (5) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (improvement in BSA, PASI, PGA, itch)

Polyarticular Juvenile Idiopathic Arthritis — Initial and continuation criteria

Covered when ALL of the following are met

Polyarticular JIA criteria: (1) Trial of at least one non‑Cytokine and CAM DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine) that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months) unless clinically inappropriate; (2) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (e.g., improvement in joint pain/swelling, activities of daily living, reduction in disease flares)

Psoriatic Arthritis — Initial and continuation criteria

Covered when ALL of the following are met

Psoriatic Arthritis criteria: (1) Trial of at least one non‑Cytokine and CAM DMARD that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months) unless clinically inappropriate; (2) Presence of active, severe disease documented by provider assessment; (3) Presence of any of: erosive disease, elevated CRP or ESR, long‑term damage interfering with function, or major quality‑of‑life impairment due to high disease activity; (4) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (e.g., improvement in joint pain/swelling, ADLs, reduced flares)

Rheumatoid Arthritis — Initial and continuation criteria

Covered when ALL of the following are met

Rheumatoid Arthritis criteria: (1) Baseline disease activity assessments submitted (e.g., DAS28‑CRP/ESR, SDAI, CDAI, RAPID3, PAS II); (2) Trial of at least one non‑Cytokine and CAM DMARD (e.g., methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, cyclosporine, azathioprine) that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months) unless clinically inappropriate; (3) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (improvement in disease activity scores such as DAS28, SDAI, CDAI, RAPID3, PAS II)

Ulcerative Colitis — Initial and continuation criteria

Covered when ALL of the following are met

Ulcerative Colitis criteria: (1) Baseline assessments submitted (e.g., stool frequency, endoscopy results, presence of rectal bleeding, disease activity scoring tool); (2) Conventional therapy (e.g., systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) has been ineffective, contraindicated, or not tolerated (minimum trial of 12 weeks) unless clinically inappropriate; (3) For continuation: documentation submitted demonstrating disease stability or a positive clinical response (e.g., decreased stool frequency, decreased rectal bleeding, improvement in endoscopic activity, tapering/discontinuation of corticosteroids, or improvement on a disease activity scoring tool)

The request form sets implicit exclusion criteria when the required prior therapy trials specified for each diagnosis are not met or are not documented as contraindicated or intolerant. Examples include failure to document trials of topical therapies or phototherapy for dermatologic indications, lack of documented trial of at least one non-Cytokine/CAM DMARD for rheumatologic indications, or absence of a documented dupilumab trial where specified. When these required prior therapies and minimum trial durations are not demonstrated, the request would be considered outside the stated coverage criteria and may be excluded from approval.

Providers should ensure that chart notes explicitly document prior therapy names, durations, and reason for discontinuation (ineffective, intolerant, or contraindicated) consistent with the minimum trial durations listed on the form (for example, topical/phototherapy 12 weeks, DMARDs 3 months, dupilumab 16 weeks, topical corticosteroids 28 days/6 weeks as indicated). Absent that documentation, the form indicates the request does not meet the prior-therapy requirement for approval.

Requests that do not include the specific prior therapy trials, baseline assessments, or objective measures of disease severity required for each diagnosis will not meet the medical necessity criteria on the form. Examples of missing or insufficient documentation include absence of SALT scoring for alopecia areata, lack of BASDAI or ASDAS for axial spondyloarthritis, missing BSA/IGA/EASI for dermatologic conditions, or omission of CDAI/DAS28/SDAI/CDAI/RAPID3 for inflammatory bowel disease and rheumatologic conditions.

For each diagnosis the form requires evidence of prior treatment trials with minimum durations and/or baseline assessments (for example: topical corticosteroids or intralesional steroids for alopecia areata with minimum trials; ≥2 NSAID trials and ≥1 non-Cytokine DMARD for axial disease; phototherapy and at least one non-CAM DMARD for plaque psoriasis; immunomodulator trial of at least 12 weeks for Crohn's disease; baseline stool frequency and endoscopy for ulcerative colitis). Failure to include these items or documentation of contraindication/intolerance will result in the request not meeting the criteria described on the form.

What the Provider Must Do to Obtain Authorization

Prior Authorization

Prior authorization required — complete form and include clinical documentation

Prior authorization is required for S1‑P receptor modulators. Complete the entire prior authorization form and provide required clinical documentation (including baseline assessments and any prior therapy trials specified for the diagnosis). Fax the completed form and documentation to 866-940-7328 and allow at least 24 hours for review.

Step Therapy

Required prior therapy trials — document trials/failures/contraindications

Many indications require documented trial and failure, intolerance, or contraindication to specified therapies before approval (examples and minimum trial durations are requested on the form and vary by diagnosis).

Topical therapies/phototherapy (e.g., phototherapy ≥12 weeks for psoriasis; topical corticosteroids ≥28 days for atopic dermatitis).
Non-Cytokine/CAM DMARDs (e.g., methotrexate, azathioprine) — commonly minimum 3 months for rheumatologic indications and 12 weeks for IBD).
Dupilumab prior trial of 16 weeks for atopic dermatitis where specified.
NSAID trial of ≥4 weeks and trial of ≥2 NSAIDs for axial spondyloarthritis.

Documentation Required

Submission requirements — complete form, chart notes, prescriber signature/specialty, fax

Submit the fully completed prior authorization form with supporting chart notes, include prescriber signature and prescriber specialty, and fax all materials to 866-940-7328 as instructed on the form.

Ensure baseline assessments and diagnosis‑specific scores are included (e.g., SALT, BASDAI/ASDAS, BSA/IGA/EASI, DAS28/CDAI/RAPID3, stool/endoscopy results where applicable).
Include documentation of prior therapy trials with durations and outcomes.

Denial Risk

Documentation missing — missing chart notes or prescriber signature may risk denial

Chart notes are required with the request and absence of required chart documentation or a prescriber signature/specialty may result in denial of the request.

The form explicitly states: 'CHART NOTES ARE REQUIRED WITH THIS REQUEST' and lists prescriber signature, prescriber specialty, and date as required elements.