CurrentUnitedHealthcarePolicy N/A

Cytokine and CAM Antagonists: IL-4/IL-13/IL-31 Inhibitors - Washington Prior Authorization Request Form

A Washington state prior authorization request form used by UnitedHealthcare to collect clinical information and documentation required to authorize IL-4/IL-13/IL-31 cytokine and CAM antagonist medications for multiple indications. Applies to prescribers and pharmacies requesting coverage through Washington (Apple Health) processes.

Policy Summary

PayerUnitedHealthcare

PolicyCytokine and CAM Antagonists: IL-4/IL-13/IL-31 Inhibitors - Washington Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with chart notes, current weight, and documentation of prior medication trials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8indications listed

24+form fields (approx.)

24-28 wksdupilumab trial for Nemolizumab

24 hmin review turnaround

Coverage Criteria by Indication

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Atopic dermatitis

Atopic dermatitis — Covered when ALL of the following are met

AD initial/continuation criteria: 1) Moderate to severe disease documented by one or more of the following: BSA involvement of at least 10%; involvement of sensitive skin areas (hands, feet, face, neck, genitalia, or intertriginous areas); or baseline disease severity scale supporting moderate to severe chronic atopic dermatitis (e.g., IGA ≥3, EASI, POEM). 2) Functional impairment related to AD such as limitations in activities of daily living, recurrent skin infections, or sleep disturbance. 3) History of failure (inability to achieve or maintain remission) to topical therapies unless contraindicated or clinically inappropriate, with minimum trials of 28 days each: medium/moderate potency topical corticosteroids; topical calcineurin inhibitors; topical PDE-4 inhibitors. 4) For continuation: documentation of disease stability or a positive clinical response (any of: ≥20% reduction in BSA from baseline; IGA 0–1; ≥50% reduction in EASI).BSA ≥10%; trials ≥28 days; response definitions as listed

Combination of checked items on form required

Asthma

Asthma — Covered when ALL of the following are met

Asthma severity and prior therapy: 1) Moderate or severe persistent asthma as specified on the form (e.g., daily symptoms, nighttime awakenings, increased SABA use, activity limitation, and FEV1 ranges consistent with moderate [FEV1 >60% to <80%] or severe [FEV1 <60%]). 2) For eosinophilic phenotype requests: blood eosinophils ≥150 cells/μL within the last 12 months when indicated. 3) History of one or more exacerbations in the prior year requiring systemic corticosteroids for ≥3 days, or hospitalization or ED visit, OR dependence on oral corticosteroids for asthma control. 4) Currently treated with maximally tolerated controller therapy (e.g., ICS/LABA with or without additional controllers such as LAMA, leukotriene receptor antagonist, or theophylline). 5) Will continue asthma controller medications with the requested drug unless contraindicated. 6) For continuation: documentation of clinical response (e.g., reduced exacerbations, improved FEV1, reduced systemic corticosteroid requirement, fewer hospitalizations).eosinophils ≥150 cells/μL where specified

Form requests confirmation of controller continuation; prior therapy and exacerbation history required

CRSwNP

Chronic rhinosinusitis with nasal polyposis (CRSwNP) — Covered when ALL of the following are met

CRSwNP criteria: 1) Bilateral sinonasal polyposis documented by endoscopy or CT. 2) Impaired health-related quality of life due to moderate to severe nasal congestion/obstruction. 3) Symptoms such as nasal discharge, facial pain/pressure, or reduction/loss of smell. 4) History of failure, contraindication, or intolerance to intranasal corticosteroids (minimum trial of 2 months) and/or oral systemic corticosteroid therapy within the last 24 months. 5) A maintenance intranasal corticosteroid will be continued with the requested drug unless contraindicated. 6) For continuation: documentation of clinical response (e.g., improvement in nasal congestion/obstruction, reduction in nasal polyps).intranasal steroid trial ≥2 months; systemic steroid within 24 months

Maintenance intranasal corticosteroid should be continued unless contraindicated

Eosinophilic esophagitis

Eosinophilic esophagitis (EoE) — Covered when ALL of the following are met

EoE criteria: 1) Symptoms consistent with EoE (e.g., dysphagia, food impaction, vomiting, central chest or upper abdominal pain). 2) Endoscopic biopsy demonstrating eosinophil-predominant inflammation with peak ≥15 eos/hpf (≈60 eos/mm2). 3) Alternative causes of esophageal eosinophilia have been excluded. 4) Persistent symptoms during or after an adequate trial of dietary restriction (minimum 2 months). 5) History of failure, contraindication, or intolerance to at least one agent in one of the following classes: proton pump inhibitors (minimum trial 2 months) or swallowed topical corticosteroids (minimum trial 12 weeks). 6) For continuation: documentation of clinical response (improvement in symptoms or reduction in eosinophils).histology ≥15 eos/hpf; PPI ≥2 months; topical steroid ≥12 weeks

Form requires documentation of trials and exclusion of other causes

Prurigo nodularis

Prurigo nodularis — Covered when ALL of the following are met

Prurigo nodularis criteria: 1) Disease severity with either ≥20 nodules for at least 3 months or a Worst-Itch Numeric Rating Scale (WI-NRS) score ≥7; and the condition is not drug-induced or due to another medical condition. 2) Trial of at least one medium to very high potency topical corticosteroid for a minimum of 4 weeks unless contraindicated. 3) History of failure or intolerance to other topical or procedural therapies with minimum trials as listed: topical calcineurin inhibitors (≥3 weeks); topical vitamin D analogue (≥3 weeks); phototherapy (UVA or PUVB) (≥1 month); or systemic immunosuppressants (e.g., methotrexate or cyclosporine) (≥3 weeks). 4) For Nemolizumab-ilto (Nemluvio): prior dupilumab treatment was ineffective, contraindicated, or not tolerated with a minimum trial of 24 weeks. 5) For continuation: documentation of disease stability or positive clinical response (reduced itch, improved skin appearance, reduction in number of nodules).WI-NRS ≥7; nodules ≥20 for ≥3 months; dupilumab trial ≥24 weeks for nemolizumab

Indication-specific prior therapy hierarchy specified

COPD

COPD — Covered when ALL of the following are met

COPD criteria: 1) Lung function measured within the last 12 months with percent predicted FEV1 between 30–70%. 2) Dyspnea score ≥2 on the Medical Research Council dyspnea scale. 3) Absolute blood eosinophil count ≥300 cells/µL within the last 12 months. 4) Patient is being treated with maximal inhaled therapy (ICS + LABA + LAMA) or on double maintenance therapy (LABA + LAMA) if ICS is contraindicated.eosinophils ≥300 cells/µL; FEV1 30–70%

Form captures these objective measures

Eosinophilic esophagitis (EoE) is excluded under this indication set when the esophageal eosinophilia is determined to be due to other allergic conditions or other defined forms of esophageal eosinophilia. The form explicitly requires confirmation that the patient’s underlying cause is NOT another allergic condition or alternative form of esophageal eosinophilia; absence of that exclusion would make the request ineligible under the EoE criteria.

Requests will be considered incomplete and may be denied if required documentation is not provided. The form requires submission of supporting chart notes and the patient’s current weight (with date), and it states CHART NOTES ARE REQUIRED WITH THIS REQUEST.

Additionally, requests that do not meet the indication-specific severity, phenotype, or prior‑therapy requirements listed on the form (for example, missing documented trials of preferred therapies or required minimum trial durations) may be considered not medically necessary and are at risk for denial.

Prior Authorization Requirements and Provider Instructions

Prior Authorization

Prior authorization form submission — complete and fax request form with supporting documentation

Complete and fax the UnitedHealthcare prior authorization request form with all supporting documentation to avoid delays. Fax: 866-940-7328. Allow at least 24 hours for review. Include date of request, reference #, patient demographics, prescriber info (including NPI), medication, directions, quantity/days supply, and whether this is a continuation of therapy with documentation of disease stability or positive clinical response.

Fax: 866-940-7328
Allow ≥24 hours for review
Include patient DOB and ProviderOne ID
Include prescriber name, NPI, telephone, fax
Specify medication, strength, directions, qty/days supply
Indicate if continuation of therapy and provide documentation of stability/response

Step Therapy

Required trials of preferred and prior therapies — try Apple Health Preferred Drug List agents before non-preferred

Try Apple Health Preferred Drug List (AHPDL) preferred Cytokine and CAM agents before requesting non-preferred products. For non-preferred requests, document each preferred agent tried, with duration of trial, or explain why preferred products were not tried or are contraindicated/intolerant.

If non-preferred, list each AHPDL medication and duration of trial
If preferred products not tried, provide clinical rationale (contraindication/intolerance)

Documentation Required

Required documentation — chart notes, current weight with date, prior medication trials, specialty involvement

Provide complete clinical documentation: chart notes (required), current weight with date, history of prior medication trials including durations, specialty involvement or consultation (e.g., allergist, dermatologist, immunologist, pulmonologist), and prescriber signature and specialty. For specific indications, include relevant severity measures and prior treatment trials as requested on the form (e.g., topical therapies, phototherapy, systemic immunosuppressants, intranasal corticosteroids, dupilumab trial when applicable).

CHART NOTES ARE REQUIRED — include clinical progress notes
Current weight in kg and date recorded
List prior medication trials with durations — include topical corticosteroids, calcineurin inhibitors, PDE-4 inhibitors, phototherapy, systemic immunosuppressants as applicable
Document specialist prescriber or consultation (check specialty on form)
Include prescriber signature and specialty

Denial Risk

Missing or insufficient documentation risk — chart notes and complete prior trial/severity evidence required

Failure to provide required documentation or to document required prior trials and disease severity/phenotype may result in denial. Chart notes that are missing or incomplete (including absence of weight/date, missing prior trial details, or lack of specialty documentation) risk denial of the request.

Missing chart notes or incomplete clinical documentation may trigger denial
Insufficient detail about prior therapy trials or duration risks denial
Lack of objective severity measures (e.g., BSA, IGA, EASI, FEV1 where applicable) or functional impairment documentation may result in denial

OpenPayer

Cytokine and CAM Antagonists: IL-4/IL-13/IL-31 Inhibitors - Washington Prior Authorization Request Form

Coverage Criteria by Indication

Medication and Clinical Coding

Prior Authorization Requirements and Provider Instructions

Background and Form Purpose

Clinical Definitions and Severity Scales