CurrentUnitedHealthcarePolicy N/A

Topical calcineurin inhibitors prior authorization (Washington)

A Washington state prior authorization request form for topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) used for atopic dermatitis, vitiligo, or other dermatologic indications; defines required documentation and trial/failure criteria for reimbursement decisions and continuations of therapy.

Policy Summary

PayerUnitedHealthcare

PolicyTopical calcineurin inhibitors prior authorization (Washington)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Washington Calcineurin Inhibitors PA form with required chart notes, baseline assessments, corticosteroid trial documentation, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursreview time

28 daysAD steroid trial

2 monthsVitiligo steroid trial

3 monthsVitiligo duration

Coverage Criteria

Approval criteria (initial and continuation)

Coverage consideration when ALL required documentation and trials are provided as applicable to indication:

Core submission requirements: Completed PA form with patient and prescriber details, medication and strength, directions, quantity/days supply, prescriber signature and specialty, and chart notes/baseline assessments

Indication-specific selection: Provider selects diagnosis: Atopic dermatitis, Vitiligo, or Other; subsequent criteria depend on selection

Atopic dermatitis-specific criteria: Documentation of baseline disease severity scoring (e.g., IGA, EASI, POEM); trial of at least one different topical corticosteroid that was ineffective, contraindicated, or not tolerated (minimum 28 days each); indicate if treatment is for sensitive areas or history of steroid-induced atrophy; for continuation, documentation of disease stability or positive clinical response from baseline (e.g., reduction in BSA, IGA 0–1, decrease in EASI)

Policy Summary

PayerUnitedHealthcare

PolicyTopical calcineurin inhibitors prior authorization (Washington)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Washington Calcineurin Inhibitors PA form with required chart notes, baseline assessments, corticosteroid trial documentation, and prescriber signature.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Vitiligo-specific criteria: Vitiligo duration >= 3 months; documentation of baseline disease/severity assessments; trial of at least one different medium-to-high potency topical corticosteroid (e.g., betamethasone, mometasone, clobetasol, fluocinonide) that was ineffective, contraindicated, or not tolerated (minimum trial of 2 months); indicate if treatment is for sensitive areas or history of steroid-induced atrophy; for continuation, documentation of improvement (e.g., F-VASI/T-VASI improvement or reduction in total BSA) from baseline

Non-preferred product requirement: If request is for a non-preferred product, document trial and failure/intolerance/contraindication to one or more preferred topical immunosuppressive medications on the Apple Health Preferred Drug List or explain why preferred products were not tried

The prior authorization form does not list any explicit coverage exclusions on the face of the form. Complete patient and prescriber information, indication selection (Atopic dermatitis, Vitiligo, or Other), medication details, and the required supporting documentation are the operative elements used to determine coverage.

The form does not enumerate specific "not medically necessary" conditions, but it makes clear that requests must include required documentation and evidence of applicable trials. Requests lacking chart notes, baseline assessments, prescriber signature, specialty, or date, or that do not demonstrate the required prior treatment trials and durations, may be delayed or denied.

Coding and Trial Durations

Topical corticosteroid trial durations — key thresholds

Atopic dermatitis corticosteroid trialTrial of at least one different topical corticosteroid that was ineffective, contraindicated, or not tolerated (minimum 28 days each)

Vitiligo corticosteroid trialTrial of at least one different medium-to-high potency topical corticosteroid (examples: betamethasone, mometasone, clobetasol, fluocinonide) that was ineffective, contraindicated, or not tolerated (minimum 2 months)

Vitiligo disease durationVitiligo duration of at least 3 months required for that diagnosis pathway

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior authorization form completion

Complete the Washington Calcineurin Inhibitors prior authorization form in full and fax it to 866-940-7328. Allow at least 24 hours for review. Incomplete forms or missing required documentation may delay or result in denial of the request.

Fax completed PA form to 866-940-7328; questions: call 800-310-6826
Allow ≥24 hours for review

Step Therapy

Preferred product and corticosteroid trial requirements

If the requested agent is non-preferred, document trials of one or more preferred topical immunosuppressive medications from the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated. For atopic dermatitis and vitiligo, document required topical corticosteroid trials per diagnosis-specific requirements below.

For non-preferred agents: list each preferred medication tried and duration
If preferred products not tried: provide clinical rationale why not tried

Step Therapy

Preferred product and corticosteroid trial requirements — diagnosis-specific details

For atopic dermatitis: submit baseline disease severity scoring (e.g., IGA, EASI, POEM) and documentation of at least one different topical corticosteroid trial (minimum 28 days) that was ineffective, contraindicated, or not tolerated. For vitiligo: document baseline assessments, disease duration ≥3 months, and at least one medium-to-high potency topical corticosteroid trial (examples: betamethasone, mometasone, clobetasol, fluocinonide) of minimum 2 months; indicate if treatment is for sensitive areas or there is steroid-induced atrophy. For continuation requests, provide documentation demonstrating disease stability or positive clinical response.

Atopic dermatitis: baseline severity score (IGA, EASI, POEM) required; topical corticosteroid trial ≥28 days
Vitiligo: disease ≥3 months; baseline assessments required; medium-to-high potency steroid trial ≥2 months; note sensitive areas or steroid atrophy
Continuation: documentation of stability or improvement (e.g., F-VASI/T-VASI improvement or reduced BSA)

Documentation Required

Required documentation / Missing documentation

Chart notes and baseline assessments are required with the prior authorization request. Prescriber signature, prescriber specialty, and date must be included. Requests missing chart notes, baseline assessments, or the prescriber signature/specialty/date may be delayed or denied.

Required: chart notes, baseline disease assessments, prescriber signature, prescriber specialty, and date
Missing required documentation may result in denial or processing delays

Definitions and Baseline Assessments

Baseline assessments required

Atopic dermatitis baseline scalesDocumentation of baseline disease severity using a validated scale (e.g., Investigator's Global Assessment [IGA], Eczema Area and Severity Index [EASI], Patient Oriented Eczema Measure [POEM])

Vitiligo baseline assessmentsDocumentation of baseline disease assessments and disease severity; may include F-VASI and/or T-VASI or total BSA involvement

Baseline and current BSAForm requests baseline and current body surface area (BSA) involvement with dates for each

Background

Topical calcineurin inhibitors (for example, tacrolimus and pimecrolimus) are positioned in this form as steroid-sparing topical immunomodulators used for dermatologic conditions such as atopic dermatitis and vitiligo, particularly where sensitive areas or concern for steroid atrophy exist. The form requests baseline and current disease severity measures and body surface area involvement to evaluate clinical necessity and response to therapy.