UnitedHealthcare Cytokine CAM/JAK Prior Auth

Alopecia areata

Covered when ALL of the following are met

Alopecia areata initiation: Current episode > 6 months; ≥50% scalp hair loss (SALT >50%); history of failure, contraindication, or intolerance to high-potency topical corticosteroids (min 6 weeks), intralesional corticosteroids (min 6 weeks), or systemic therapy (e.g., oral corticosteroids, methotrexate, cyclosporine) (min 6 weeks)SALT>50%

See questions 7-9

Alopecia areata continuation: Documentation submitted demonstrating a positive clinical response (improvement in SALT score)

See question 10

Ankylosing Spondylitis / Non-radiographic axial spondyloarthritis

Covered when ALL of the following are met

Ankylosing spondylitis initiation: High disease activity indicated by BASDAI ≥4 OR ASDAS ≥2.1; treatment with at least two different NSAIDs ineffective/contraindicated/not tolerated (min 4 weeks); disease manifesting as axial disease or peripheral arthritis; trial of at least one non-Cytokine and CAM DMARD ineffective/contraindicated/not tolerated (min 3 months) if applicableBASDAI>=4 or ASDAS>=2.1

See questions 11-14

Ankylosing spondylitis continuation: Documentation demonstrating disease stability or a positive clinical response (e.g., decrease in BASDAI or ASDAS)

See question 15

Atopic dermatitis

Covered when ALL of the following are met

Atopic dermatitis initiation: Disease severity consistent with moderate-to-severe disease (e.g., IGA ≥3, EASI, POEM, or BSA ≥10%); involvement of sensitive areas or functional impairment; history of failure or intolerance to topical corticosteroids of at least medium/moderate potency, topical calcineurin inhibitors, and topical PDE-4 inhibitors (minimum trial of 28 days each) unless contraindicatedIGA>=3 or BSA>=10%

See questions 16-18

Atopic dermatitis continuation: Documentation of disease stability or positive clinical response defined by ≥20% reduction in BSA from baseline OR IGA 0/1 OR ≥50% decrease in EASI OR improvement in functional impairment>=20% BSA reduction or EASI>=50%

See question 19

Crohn's Disease

Covered when ALL of the following are met

Crohn's Disease initiation: History of ineffective/contraindicated/intolerant conventional therapies (e.g., short-term oral corticosteroids to induce remission; immunomodulator trial such as methotrexate, azathioprine, 6-mercaptopurine for minimum 12 weeks); documentation of high-risk disease features (e.g., obstruction, abscess, stricture, fistula, resection, extensive involvement, early age of onset, growth retardation, CDAI >450, Harvey-Bradshaw >7)CDAI>450 or Harvey-Bradshaw>7

See questions 20-21

Crohn's continuation: Documentation demonstrating disease stability or a positive clinical response (e.g., endoscopic improvement, corticosteroid taper/discontinuation, reduction in liquid stools, decreased abdominal pain, decreased CDAI or Harvey-Bradshaw index)

See question 22

Plaque Psoriasis

Covered when ALL of the following are met

Plaque psoriasis initiation: Ongoing disease >6 months; disease affecting at least 10% BSA or involving face/ears/hands/feet/genitalia; baseline assessments submitted (e.g., BSA, PASI, PGA, itch numeric rating); history of failure, contraindication, or intolerance to phototherapy (UVB or PUVA) (min 12 weeks) and treatment with at least one non-Cytokine and CAM DMARD (min 12 weeks)BSA>=10%

See questions 23-26

Plaque psoriasis continuation: Documentation of disease stability or positive clinical response (e.g., improvement in BSA, PASI, Psoriasis PGA, itch numeric rating scale)

See question 27

Polyarticular Juvenile Idiopathic Arthritis

Covered when ALL of the following are met

PJIA initiation: Treatment with at least one non-Cytokine and CAM DMARD that has been ineffective unless all are contraindicated or not tolerated (minimum trial of 3 months)

See question 28

PJIA continuation: Documentation demonstrating disease stability or a positive clinical response (e.g., improvement in joint pain, swelling, activities of daily living, reduction in disease flares)

See question 29

Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic Arthritis initiation: Treatment with at least one non-Cytokine and CAM DMARD that has been ineffective, contraindicated, or not tolerated (minimum trial of 3 months); presence of active, severe disease by provider assessment; presence of erosive disease, elevated CRP/ESR, long-term damage interfering with function, or major impairment of quality of life due to high disease activity

See questions 30-32

Psoriatic Arthritis continuation: Documentation demonstrating disease stability or a positive clinical response (e.g., improvement in joint pain, swelling, activities of daily living, reduction in disease flares)

See question 33

Rheumatoid Arthritis

Covered when ALL of the following are met

Rheumatoid Arthritis initiation: Baseline disease activity assessments submitted (e.g., DAS28-CRP/ESR, SDAI, CDAI, RAPID3, PAS II); treatment with at least one non-Cytokine and CAM DMARD that has been ineffective unless contraindicated or not tolerated (minimum trial of 3 months)

See questions 34-35

Rheumatoid Arthritis continuation: Documentation demonstrating disease stability or a positive clinical response (e.g., improvement in DAS28-CRP/ESR, SDAI, CDAI, RAPID3, PAS II scores)

See question 36

Ulcerative Colitis

Covered when ALL of the following are met

Ulcerative Colitis initiation: Baseline assessments submitted (e.g., stool frequency, endoscopy results, presence of rectal bleeding, disease activity scoring tool); treatment with conventional therapy ineffective unless contraindicated or not tolerated (minimum trial of 12 weeks)

See questions 37-38

Ulcerative Colitis continuation: Documentation demonstrating disease stability or a positive clinical response (e.g., decreased stool frequency, decreased rectal bleeding, endoscopic improvement, corticosteroid taper/discontinuation, or improvement on a disease activity scoring tool)

See question 39

Vitiligo

Covered when ALL of the following are met

Vitiligo initiation: Chronic vitiligo > 3 months; total BSA involvement ≤ 10%; history of ineffective or not tolerated topical therapies or phototherapy with minimum trial of 2 months (phototherapy, topical calcineurin inhibitors, medium-to-high potency topical corticosteroids)BSA<=10% and duration>3 months

See questions 40-42

Vitiligo continuation: Documentation demonstrating a positive clinical response (e.g., improvement in F-VASI and/or T-VASI score from baseline or reduction in total BSA involvement)

See question 43

Chronic hand eczema

Covered when ALL of the following are met

Chronic hand eczema initiation: Documentation that BSA involvement does not exceed 20%; functional impairment due to chronic hand eczema documented; history of failure or intolerance to topical corticosteroids (medium/moderate potency), topical calcineurin inhibitors, and topical PDE-4 inhibitors (minimum trial of 28 days each); trial of dupilumab (16 weeks) ineffective, contraindicated, or not toleratedBSA<=20%

See questions 44-47

Chronic hand eczema continuation: Documentation of disease stability or positive clinical response defined by ≥20% reduction in BSA from baseline OR IGA 0/1 OR ≥50% decrease in EASI OR improvement in functional impairment>=20% BSA reduction or EASI>=50%

See question 48

This prior authorization request form does not list a single, universal exclusion list. Coverage for Cytokine and CAM antagonists (including Janus Associated Kinase [JAK] inhibitors) is determined per indication by meeting the indication‑specific coverage criteria

Requests that do not include the required supporting information identified for the selected diagnosis are effectively not meeting medical necessity as defined by the form. Specifically, absence of documentation for required prior therapy trials, missing baseline disease activity assessments, or lack of evidence of response/stability for continuation requests may lead to denial or delay because they do not demonstrate the indication‑specific criteria have been met.

Scores, Thresholds, and Key Definitions

Alopecia areata — SALT score threshold

SALT score threshold for alopecia areataSALT (Severity of Alopecia Tool) score greater than 50% (SALT >50%)

Current episode duration requirementPatient's current episode of alopecia areata must be lasting more than 6 months

Prior therapy requirementHistory of failure, contraindication, or intolerance to high‑potency topical corticosteroids, intralesional corticosteroids, or systemic therapy (minimum trials specified)

Ankylosing spondylitis — BASDAI threshold

BASDAI disease activity thresholdBath Ankylosing Spondylitis Disease Activity Index (BASDAI) score of at least 4 (BASDAI >= 4)

Alternative disease activity measureAnkylosing Spondylitis Disease Activity Score (ASDAS) ≥ 2.1 may be used as an alternative to BASDAI

Required NSAID trialTreatment with at least two different NSAIDs ineffective/contraindicated/not tolerated (minimum trial 4 weeks)

Ankylosing spondylitis — ASDAS threshold

ASDAS disease activity thresholdAnkylosing Spondylitis Disease Activity Score (ASDAS) of at least 2.1 (ASDAS >= 2.1)

BASDAI alternativeBASDAI ≥ 4 may be used as an alternative to ASDAS to document high disease activity

Continuation documentationFor continuation, submit documentation demonstrating disease stability or positive clinical response (e.g., decrease in BASDAI or ASDAS)

Vitiligo — duration requirement

Minimum duration for vitiligoVitiligo must be chronic for more than 3 months (duration > 3 months)

Prior topical/phototherapy trialsTrial of topical therapies or phototherapy for a minimum of 2 months (unless ineffective or not tolerated) is required

Continuation requirementFor continuation, documentation of positive clinical response (improvement in F‑VASI and/or T‑VASI or reduction in total BSA) must be submitted

Vitiligo — BSA involvement

Vitiligo total BSA limitTotal body surface area (BSA) involvement must be 10% or less (BSA ≤ 10%)

Treatment history requirementDocumented ineffective or not tolerated treatment with phototherapy, topical calcineurin inhibitors, or medium‑to‑high potency topical corticosteroids (minimum trial 2 months)

Continuation documentationFor continuation, submit documentation demonstrating positive clinical response (improvement in F‑VASI/T‑VASI or reduction in total BSA)

SALT score — definition and use

Definition of SALT scoreSALT = Severity of Alopecia Tool; used to quantify scalp hair loss; form defines extensive scalp hair loss as SALT >50%

Use in initiation criteriaSALT >50% is required as part of initiation criteria for alopecia areata (with current episode >6 months and prior therapy failure)

Use in continuation criteriaImprovement in SALT score must be documented for continuation requests

BASDAI / ASDAS — definitions and application

BASDAI definition/useBASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is used to document high disease activity; a BASDAI score ≥ 4 meets the form's threshold

ASDAS definition/useASDAS (Ankylosing Spondylitis Disease Activity Score) is an alternative disease activity index; ASDAS ≥ 2.1 meets the form's threshold

Context of applicationBASDAI or ASDAS scores are required for initiation and decreases in these scores support continuation of therapy

Atopic dermatitis — severity scales

IGA for atopic dermatitisInvestigator's Global Assessment (IGA) score of 3 or greater indicates moderate‑to‑severe atopic dermatitis and is an accepted baseline severity measure

EASI and POEMEczema Area and Severity Index (EASI) and Patient Oriented Eczema Measure (POEM) are also accepted baseline severity scales to support moderate‑to‑severe disease

Response criteria for continuationContinuation may be supported by ≥20% reduction in BSA from baseline, IGA of 0/1, or ≥50% decrease in EASI; improvement in functional impairment is also acceptable

What Providers Must Do When Submitting Requests

Prior Authorization
Prior authorization required — complete Washington PA form
Prior authorization is required for Cytokine and CAM antagonists (including JAK inhibitors). Providers must complete the Washington Prior Authorization Request Form and submit it with supporting documentation as described on the form.

Step Therapy
Prior therapy trials required (meet indication-specific minimums)
Many indications require documented trials of specified prior therapies (topical/systemic corticosteroids, topical calcineurin inhibitors, phototherapy, non‑biologic DMARDs, NSAIDs, immunomodulators, or dupilumab) with minimum trial durations listed per indication before approval of non-preferred or advanced agents.
Alopecia areata: high‑potency topical, intralesional, or systemic therapy (minimum 6 weeks each) [[see cited chunks]]
Ankylosing spondylitis: at least two different NSAIDs (minimum 4 weeks) and at least one non‑Cytokine DMARD if applicable (minimum 3 months)
Atopic dermatitis: topical corticosteroids, topical calcineurin inhibitors, topical PDE‑4 inhibitors (minimum 28 days each)
Crohn's/Ulcerative Colitis: conventional therapies (e.g., corticosteroids, immunomodulators) with minimum trials (Crohn's immunomodulator ≥12 weeks; UC conventional therapy ≥12 weeks)
Psoriasis/Psoriatic arthritis/RA/PJIA: trial of at least one non‑Cytokine DMARD (minimum 3 months) or phototherapy (psoriasis minimum 12 weeks)
Chronic hand eczema: topical therapies (minimum 28 days each) and dupilumab (minimum 16 weeks) where specified
Vitiligo: phototherapy/topicals (minimum 2 months)

Documentation Required
Required baseline assessments — submit disease activity scores and objective measures
Submit baseline disease activity assessments and objective measures relevant to the diagnosis (disease activity scores, BSA/PASI/IGA/EASI, endoscopy/stool frequency, CDAI/Harvey‑Bradshaw, DAS28/SDAI/CDAI/RAPID3, BASDAI/ASDAS) as applicable to support initiation and continuation requests.
Rheumatoid arthritis: DAS28 (CRP/ESR), SDAI, CDAI, RAPID3, PAS II
Ankylosing spondylitis: BASDAI ≥4 or ASDAS ≥2.1
Dermatologic conditions: BSA, PASI, IGA, EASI, SALT for alopecia areata (SALT >50%)
Gastrointestinal: stool frequency, endoscopy results, CDAI or Harvey‑Bradshaw for Crohn's/UC

Note
Submission instructions — complete form, attach chart notes, fax to 866-940-7328
Complete the entire Washington PA form and include chart notes; fax the completed form and documentation to 866-940-7328. Allow at least 24 hours for review of the request.
Fax number for submission: 866-940-7328
Allow at least 24 hours for review

Denial Risk
Missing chart notes may cause denial or delay
Chart notes are required with the PA request; submissions without chart notes may be denied or delayed.

Denial Risk
Insufficient clinical documentation may lead to denial
Failure to document required prior therapy trials, baseline assessments, or evidence of response/stability for continuation requests may result in denial of the request.

OpenPayer

Cytokine and CAM Antagonists / JAK Inhibitors prior authorization form (Washington)

Indication-Specific Coverage Criteria

Scores, Thresholds, and Key Definitions

What Providers Must Do When Submitting Requests

Policy Context and Purpose