CurrentUnitedHealthcarePolicy N/A

Cytokine & CAM Antagonists: IL-17 Inhibitors - Washington Prior Authorization Request Form

Prior authorization form and clinical criteria for IL-17 inhibitor therapies for Washington (Apple Health) members; used by prescribers to request new or continued coverage for IL-17 cytokine & CAM antagonist medications.

Policy Summary

PayerUnitedHealthcare

PolicyIL-17 inhibitor prior authorization request form (Washington)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to 866-940-7328, including member and provider sections, clinical documentation, prior medication trials, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiple indicationsdiagnoses covered on form

Prior therapy requirementsminimum trials requested

24+ hrsreview turnaround time

Faxsubmission channel

Coverage Criteria

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Initial and continuation therapy criteria

Coverage is considered when ALL relevant diagnosis-specific criteria and documentation requirements are met:

General requirements

Request type: Request must indicate new therapy or continuation; for continuation, clinical documentation demonstrating disease stability or a positive clinical response is required.
Chunk 6

Ankylosing Spondylitis / non-radiographic axial spondyloarthritis: Must have high disease activity indicated by BASDAI >= 4 or ASDAS >= 2.1; history of trial with at least two different NSAIDs that were ineffective, contraindicated, or not tolerated; and trial of at least one non-Cytokine DMARD that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months), unless contraindicated or not tolerated.

Chunks 6,7

Enthesitis-related arthritis: Trial of at least one non-Cytokine DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine) that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months), unless contraindicated or not tolerated; for continuation, documentation of disease stability or positive clinical response is required.

Chunk 9

Hidradenitis Suppurativa: Presence of inflammatory nodules and/or abscesses with Hurley Stage II or III disease; history of failure, contraindication, or intolerance to at least one oral antibiotic (e.g., doxycycline, minocycline, tetracycline, clindamycin + rifampin) with a minimum 3-month trial; for continuation, documentation of response or stability is required.

Chunk 10

Plaque Psoriasis: Ongoing disease for greater than 6 months and either disease affecting at least 10% body surface area or involvement of face/ears/hands/feet/genitalia; baseline assessments submitted when indicated (e.g., BSA, PASI, PGA, itch NRS); history of failure, contraindication, or intolerance to phototherapy (UVB or PUVA) with minimum 12-week trial and/or at least one non-Cytokine DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) with minimum 12-week trial as applicable; for continuation, documentation of disease stability or positive clinical response is required.

Chunk 11

Psoriatic Arthritis: Trial of at least one non-Cytokine DMARD that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months), unless contraindicated or not tolerated; presence of active, severe disease (provider assessment) and objective findings such as erosive disease, elevated CRP/ESR, long-term damage interfering with function, or major impairment of quality of life support medical necessity; for continuation, documentation of disease stability or positive clinical response is required.

Chunks 12,13

When a request is for a non-preferred IL-17 agent, the prior authorization form requires the provider to either document prior trials of one or more preferred Cytokine & CAM medications from the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated, including the medication names and durations, or to provide a clear written explanation of why preferred products were not tried. The form includes a dedicated section to list previous medication trials and a prompt (Section E) to explain why preferred medications would not meet the patient’s needs; failure to complete this information may prevent approval of a non-preferred product.

Coding and Assessment Thresholds

Diagnosis codes (requested)ICD-10

ICD-10 CODE

Requested diagnosis code — form requests provider to supply specific ICD-10 code for diagnosis

inv-05: BASDAI — threshold value for high disease activity

BASDAI thresholdBASDAI score of at least 4

ContextUsed to indicate high disease activity for Ankylosing Spondylitis (AS) or non-radiographic axial spondyloarthritis on the prior authorization form

DocumentationForm requires the BASDAI score to be reported on the clinical information section (question 7)

inv-06: ASDAS — threshold value for high disease activity

ASDAS thresholdASDAS score of at least 2.1

ContextUsed to indicate high disease activity for Ankylosing Spondylitis (AS) or non-radiographic axial spondyloarthritis on the prior authorization form

DocumentationForm requests the ASDAS score on the clinical information section (question 7)

inv-07: Plaque psoriasis duration — disease duration requirement

Duration requirementOngoing plaque psoriasis for greater than 6 months

ContextRequired as part of plaque psoriasis criteria on the prior authorization form (question 18)

Continuation noteFor continuation requests, documentation demonstrating disease stability or positive response is required (question 22)

Provider Actions and Submission Requirements

Prior Authorization

Submission Requirements

Complete and fax the prior authorization form to 866-940-7328. Include both member and provider sections and allow at least 24 hours for review.

Fax: 866-940-7328
Questions: 800-310-6826
Allow ≥ 24 hours for review

Step Therapy

Preferred Product Trials for Non-Preferred Requests

If requesting a non-preferred product, document trials of preferred Cytokine and CAM medications listed on the Apple Health Preferred Drug List (AHPDL). For each preferred medication tried, include the medication name and duration of trial, or explain why preferred products were not tried or are inappropriate.

List each preferred medication tried and duration
Or provide reason preferred products were not tried (contraindication, intolerance, or inefficacy)
Refer to the AHPDL for preferred alternatives

Documentation Required

Required Documentation and Missing Documentation Risk

Chart notes documenting clinical status and prior treatment trials are required. The request must include prescriber signature, prescriber specialty, and date. Missing documentation or missing prescriber signature may lead to denial or processing delays.

Attach chart notes showing disease history, baseline assessments, and prior medication trials
Prescriber signature, specialty, and date are required
Baseline assessments for plaque psoriasis (BSA, PASI, PGA, itch NRS) when applicable

Denial Risk

Insufficient Prior Therapy Documentation — Denial Risk

Insufficient documentation of required prior therapies or baseline assessments may result in denial. Ensure documentation of required prior therapy trials (e.g., NSAID/DMARD/antibiotic/phototherapy as applicable) with minimum trial durations where specified.

Phototherapy (UVB or PUVA) — minimum 12-week trial when applicable
At least one non-Cytokine and CAM DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) — minimum 12-week trial when applicable
Document trials, reasons for failure/discontinuation, and dates of therapy in Section D

Background

Interleukin-17 (IL-17) inhibitors are included on the Cytokine & CAM Antagonists prior authorization form for treatment of inflammatory conditions such as ankylosing spondylitis, non-radiographic axial spondyloarthritis, psoriatic arthritis, plaque psoriasis, hidradenitis suppurativa, and enthesitis-related arthritis. The form requests diagnosis-specific information to support medical necessity: for axial spondyloarthritis it requires documentation of high disease activity (for example, BASDAI ≥ 4 or ASDAS ≥ 2.1), for plaque psoriasis it requests duration (> 6 months) and baseline assessments (BSA, PASI, PGA, itch NRS) when indicated, and for other diagnoses it requests prior therapy trials and objective findings as applicable. These requirements are intended to ensure IL-17 therapy is used when prior standard therapies have failed, are contraindicated, or not tolerated and when objective measures support ongoing need.

Definitions and Clinical Thresholds

inv-15: High disease activity (AS or nr-axSpA) — BASDAI >=4 or ASDAS >=2.1 as indicated on the form

High disease activity definitionBASDAI score of at least 4 OR ASDAS score of at least 2.1

Applicable diagnosesAnkylosing Spondylitis (AS) or Non-radiographic axial spondyloarthritis (nr-axSpA)

Form locationIndicated in Clinical and Drug Specific Information, question 7

inv-16: Plaque psoriasis baseline assessments — examples include BSA, PASI, PGA, itch NRS

Examples of baseline assessmentsBody Surface Area (BSA), Psoriasis Area and Severity Index (PASI), Psoriasis Physician's Global Assessment (PGA), itch numeric rating scale (NRS)

Form questionForm asks whether baseline assessments have been submitted (question 20)

Use caseBaseline assessments are requested when indicated to support plaque psoriasis medical necessity