CurrentUnitedHealthcarePolicy N/A

Prior authorization request form for Cytokine and CAM medications (Immunology/Rheumatology indications)

This document is a UnitedHealthcare prior authorization request form used to request coverage for cytokine and cell adhesion molecule (CAM) biologic or targeted therapies across multiple immunology/rheumatology indications (e.g., alopecia areata, ankylosing spondylitis, atopic dermatitis, Crohn's disease, plaque psoriasis, juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis). It guides required clinical information and step/failed therapy documentation needed to support a PA decision.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization request form for Cytokine and CAM medications (Immunology/Rheumatology indications)

Policy CodePolicy N/A

Change TypeAdministrative form (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionFax the fully completed prior authorization form with required chart notes, prescriber signature, and specialty to 866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10+diagnoses supported on form

24hminimum review turnaround (allow at least)

866-940-7328fax number to submit PA

Policy summary & scope

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.

Prior authorization for Cytokine and CAM medications (Immunology/Rheumatology indications) — CURRENT: This administrative prior authorization form is intended to collect the clinical information UnitedHealthcare requires to evaluate requests for biologic or targeted Cytokine and CAM medications across multiple immunology and rheumatology indications (for example: alopecia areata, ankylosing spondylitis/non-radiographic axial spondyloarthritis, atopic dermatitis, Crohn's disease, plaque psoriasis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis).

The form captures disease-specific severity measures, prior therapy trials, baseline assessments, and continuation criteria needed to support a coverage decision. Providers should complete all pages, include required chart notes, and allow at least 24 hours for review.

At-a-glance

diagnoses supported on form10+ indications

minimum review turnaround (allow at least)24 hours

fax number to submit PA866-940-7328

Indication-specific prior authorization criteria

General prior authorization requirements

The request will be reviewed when all applicable clinical information and documentation are provided; chart notes are required and prescriber signature and specialty must be included.

ALL of the following

Completed PA request form with patient demographics, provider info, medication name/strength, directions, quantity/days supply, and prescriber signature
Chart notes are required and must be submitted with the request
If continuation of therapy, provide documentation showing disease stability or positive clinical response (document specifics vary by indication)
If non-preferred product requested, document trials of preferred Cytokine and CAM medications from the Apple Health Preferred Drug List unless contraindicated or not tolerated
List drug names and durations
Indicate whether medication will be used in combination with another Cytokine and CAM medication
Combination therapy flagged on form

ALL of the following

Allow at least 24 hours for review of the completed request

ALL of the following

Fax the fully completed prior authorization form and required chart notes to 866-940-7328; include prescriber signature and specialty
If questions, provider may call 800-310-6826

Alopecia areata

Coverage consideration requires ALL of the following when this diagnosis is selected:

ALL of the following

Current episode of alopecia areata lasting more than 6 months
≥50% scalp hair loss (SALT score >50%)
History of failure to at least one of
- High-potency topical corticosteroids (minimum trial 6 weeks)
- Intralesional corticosteroids (minimum trial 6 weeks)
- Systemic therapy (e.g., oral corticosteroids, methotrexate, cyclosporine) (minimum trial 6 weeks)

Ankylosing spondylitis / Non-radiographic axial spondyloarthritis

Coverage consideration requires ALL of the following:

ALL of the following

High disease activity demonstrated by one of
- BASDAI score ≥ 4>= 4
- ASDAS score ≥ 2.1>= 2.1
Trial of at least two different NSAIDs that were ineffective, contraindicated, or not tolerated (minimum trial 4 weeks)
Disease manifested as axial disease or peripheral arthritis

Atopic dermatitis

Coverage consideration requires documentation of severity and prior therapy failures as applicable:

ALL of the following

Severity (one or more)
- BSA involvement ≥ 10%>= 10% BSA
- Involvement of sensitive areas (hands, feet, face, neck, genitalia, intertriginous)
- Severe chronic disease on validated scale (e.g., IGA ≥ 3, EASI, POEM)
Functional impairment (one or more)
- Impaired activities of daily living

Crohn's disease

Coverage consideration requires ALL of the following where applicable:

ALL of the following

Failure, contraindication, or intolerance to conventional therapies (e.g., short-term oral corticosteroids for induction; immunomodulator such as methotrexate, azathioprine, 6-MP) with immunomodulator trial minimum 12 weeks
Documentation of high-risk disease (e.g., symptoms despite conventional therapy, obstruction, abscess, stricture, phlegmon, fistulas, resection, extensive bowel involvement, early onset, growth retardation, CDAI > 450, Harvey-Bradshaw index > 7)
Providers should document specific high-risk features or scores
For continuation: documentation of disease stability or positive clinical response (examples listed)

Plaque psoriasis

Coverage consideration requires ALL of the following:

ALL of the following

Ongoing disease > 6 months
Severity/location
- Disease affects at least 10% body surface area>= 10% BSA
- Disease affects the face, ears, hands, feet, or genitalia
Baseline assessments submitted (e.g., BSA, PASI, PGA)
Prior therapies

Polyarticular Juvenile Idiopathic Arthritis (pJIA)

Coverage consideration requires ALL of the following:

ALL of the following

Trial of at least one non-Cytokine/CAM DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine) unless contraindicated or not tolerated (minimum trial 3 months)
For continuation: documentation of disease stability or positive clinical response (improvement in joint symptoms, ADLs, flare reduction)

Psoriatic arthritis (PsA)

Coverage consideration requires ALL of the following:

ALL of the following

Trial of at least one non-Cytokine/CAM DMARD ineffective, contraindicated, or not tolerated (minimum trial 3 months)
Provider assessment of active, severe disease
Presence of at least one poor prognostic or severe feature
- Erosive disease
- Elevated CRP or ESR
- Long-term damage interfering with function (e.g., joint deformities, vision loss)

Rheumatoid arthritis (RA)

Coverage consideration requires ALL of the following:

ALL of the following

Baseline disease activity assessments submitted (e.g., DAS28-CRP/ESR, SDAI, CDAI, RAPID3, PAS II)
Trial of at least one non-Cytokine/CAM DMARD (e.g., methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, cyclosporine, azathioprine) unless contraindicated or not tolerated (minimum trial 3 months)
For continuation: documentation of disease stability or positive clinical response (improvement in listed disease activity scores)

Ulcerative colitis (UC)

Coverage consideration requires ALL of the following:

ALL of the following

Baseline assessments submitted (e.g., stool frequency, endoscopy results, rectal bleeding, disease activity score)
Failure, contraindication, or intolerance to conventional therapy (e.g., systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) unless contraindicated (minimum trial 12 weeks)
For continuation: documentation of disease stability or a positive clinical response (examples provided)

Numerical thresholds and required measures

Clinical thresholds and minimum trial durations

Alopecia areata duration> 6 months

Alopecia areata SALTSALT score > 50% (>=50% scalp hair loss)

Atopic dermatitis BSA>= 10% BSA

Atopic dermatitis IGAIGA score >= 3 for severe chronic disease

Atopic dermatitis dupilumab trialminimum 16 weeks

Topical therapy trials for atopic dermatitisminimum 28 days each

Phototherapy trial for plaque psoriasisminimum 12 weeks

Non-Cytokine DMARD trial (adult rheumatologic indications)minimum 3 months

NSAID trial for axial diseaseminimum 4 weeks, at least two different NSAIDs

Immunomodulator trial for Crohn's diseaseminimum 12 weeks

What providers must do

Prior Authorization

Submit completed PA form with chart notes

Fax the fully completed prior authorization form and required chart notes to 866-940-7328. The submission must include the prescriber signature and the prescriber's specialty.

Fax: 866-940-7328

Documentation Required

Document prior therapy trials

For non-preferred requests and most diagnoses, document prior therapy trials including drug names, durations, and reason for discontinuation; if a preferred product was not tried, explain why or document contraindication/intolerance as requested on the form.

List each medication and duration of trial as requested on the form
Provide reason for discontinuation (ineffective, contraindicated, or not tolerated)

Documentation Required

Provide continuation evidence

For continuation requests, provide documentation demonstrating disease stability or a positive clinical response using the metric(s) listed for the selected diagnosis (examples include BASDAI/ASDAS for axial disease, EASI/IGA/BSA for atopic dermatitis, and DAS28/SDAI/CDAI for rheumatoid arthritis).

Axial disease: BASDAI ≥4 or ASDAS ≥2.1
Atopic dermatitis: EASI reduction, IGA 0–1, or ≥20% BSA reduction
Rheumatoid arthritis: improvement in DAS28, SDAI, or CDAI scores

Prior Authorization

Allow time for review

Allow at least 24 hours for review after submitting the completed request.

Submission contacts and codes

Submission / contact informationmixed

866-940-7328	Fax number to submit prior authorization request
800-310-6826	Provider phone number for questions

Submission/contact informationmixed

866-940-7328	Fax number to submit prior authorization request
800-310-6826	Provider phone number for questions

Submit the fully completed prior authorization form and required chart notes by fax to 866-940-7328. Chart notes are required with the request, and the submission must include the prescriber's signature and prescriber specialty to be accepted for review.

Terms used in this form

Cytokine and CAM medicationsBiologic or targeted therapies that inhibit cytokines or cell adhesion molecules used to treat immune-mediated diseases (as referenced by the form).

Continuation of therapyA request to continue an ongoing medication; requires documentation of disease stability or positive clinical response.

Chart notes requirementChart notes are required with the request; prescriber signature and specialty must be included.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization request form for Cytokine and CAM medications (Immunology/Rheumatology indications)

Policy CodePolicy N/A

Change TypeAdministrative form (no material clinical changes)

Effective DateN/A

Next Review DateN/A

Key ActionFax the fully completed prior authorization form with required chart notes, prescriber signature, and specialty to 866-940-7328.

SourceLink

On This Page

For continuation: documentation of positive clinical response

Trial of at least one non-Cytokine/CAM DMARD ineffective, contraindicated or not tolerated (minimum trial 3 months)

For continuation: documentation of disease stability or positive clinical response (e.g., decrease in BASDAI or ASDAS)

Failure of prior topical therapies (unless contraindicated)

Topical corticosteroids at least medium/moderate potency (minimum trial 28 days)
Topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) (minimum trial 28 days)
Topical PDE-4 inhibitor (e.g., crisaborole) (minimum trial 28 days)

Trial of dupilumab (Dupixent) ineffective, contraindicated, or not tolerated (minimum trial 16 weeks)

For continuation: documentation of positive clinical response defined by one or more: ≥20% reduction in BSA, IGA 0-1 from baseline, ≥50% decrease in EASI, or improvement in functional impairment>= 20% BSA reduction; IGA 0-1; >=50% EASI reduction

Phototherapy (UVB or PUVA) minimum trial 12 weeks

At least one non-Cytokine/CAM DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) minimum trial 12 weeks

For continuation: documentation of disease stability or positive clinical response (improvement in BSA, PASI, PGA, itch scale)

Major impairment of quality of life due to high disease activity at many sites or functionally limiting arthritis at a few sites (including dactylitis, enthesitis)

For continuation: documentation of disease stability or positive clinical response