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 for medications that antagonize IL-4, IL-13, and IL-31 pathways; it specifies documentation, indication-specific severity measures, prior therapy trials and minimum durations, and criteria required for initiation or continuation of these agents across listed indications.

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

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Washington prior authorization form with required chart notes, prescriber signature, specialty, and objective clinical data (e.g., weight, lung function, eosinophil counts, biopsy results) via fax to 866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7diagnoses/indications covered

24+checklist items on form

24 hrsreview allowance time

fax: 866-940-7328submission fax

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inv-01: Atopic dermatitis - Initial Therapy

Covered when ALL of the following are met

Atopic dermatitis initial criteria: Patient meets disease severity criteria (one or more): BSA involvement ≥10%, involvement of sensitive areas (hands, feet, face, neck, genitalia, intertriginous), or baseline validated severity scale supporting moderate-to-severe disease (e.g., IGA ≥3, EASI, POEM)BSA ≥10%; IGA ≥3

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Functional impairment: Patient has functional impairment due to atopic dermatitis (e.g., interference with activities of daily living, recurrent skin infections, sleep disturbance)

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Prior therapy failure: History of failure (inability to achieve or maintain remission), contraindication, or intolerance to topical therapies unless all are inappropriate: topical corticosteroids (at least medium potency) AND topical calcineurin inhibitors AND topical PDE-4 inhibitors; minimum trial of 28 days each where applicableminimum trial of 28-days each

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Dupilumab trial for specific agents: For lebrikizumab, nemolizumab, or tralokinumab requests: dupilumab must have been ineffective, contraindicated, or not tolerated (minimum trial of 16 weeks)16 weeks

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inv-02: Atopic dermatitis - Continuation Therapy

Covered when ANY of the following demonstrate disease stability or positive response

Atopic dermatitis continuation criteria: Reduction in body surface area involvement of at least 20% from baseline≥20%

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Atopic dermatitis continuation criteria: Achieved or maintained clear or minimal disease (equivalent to IGA 0 or 1)IGA 0-1

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Atopic dermatitis continuation criteria: Decrease in EASI score of at least 50% from baseline≥50% EASI reduction

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inv-03: Asthma - Initial Therapy

Covered when ALL of the following are met

Asthma severity: Patient meets moderate or severe asthma criteria per checklist (symptom frequency, nighttime awakenings, SABA use, activity limitation, lung function) consistent with moderate or severe categoriessee chunks 4-5

Phenotype or exacerbation history: Either eosinophilic phenotype defined by blood eosinophils ≥150 cells/µL within the last 12 months OR one or more exacerbations in the previous year requiring systemic corticosteroids (≥3 days), hospitalization, or ED visiteosinophils ≥150 cells/µL or ≥1 significant exacerbation

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Controller therapy: Patient is being treated with or has trialed maximally tolerated inhaled controller therapy (e.g., maximally tolerated ICS/LABA or medium‑to‑high dose ICS plus an additional controller); controller therapy should be continued with the biologic unless contraindicated

inv-04: Asthma - Continuation Therapy

Covered when documentation demonstrates disease stability or positive clinical response

Asthma continuation: Documentation of disease stability or positive clinical response, for example reduced asthma exacerbations, improved FEV1 or other lung function measures, reduced systemic corticosteroid requirements, or reduced hospitalizations

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inv-05: CRSwNP - Initial Therapy

Covered when ALL of the following are met

Anatomic confirmation: Diagnosis of bilateral sinonasal polyposis confirmed by nasal endoscopy or computed tomography (CT)

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Symptom severity/HRQoL: Impaired health-related quality of life due to moderate-to-severe nasal congestion, blockage, or obstruction

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Prior therapy: History of failure, contraindication, or intolerance to intranasal corticosteroids (minimum trial of 2 months) and/or recent oral systemic corticosteroid therapy within the last 24 monthsintranasal corticosteroids ≥2 months; oral systemic corticosteroid within 24 months

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inv-06: Eosinophilic Esophagitis - Initial Therapy

Covered when ALL of the following are met

Symptoms and histology: Symptoms consistent with eosinophilic esophagitis (e.g., dysphagia, food impaction, vomiting, chest/upper abdominal pain) AND esophageal biopsy demonstrating eosinophil‑predominant inflammation with peak ≥15 eos/hpf (~60 eos/mm2), with other causes excluded≥15 eos/hpf

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Dietary trial: Persistent symptoms during or after an adequate trial of dietary restriction/empiric elimination diet (minimum trial of 2 months)≥2 months

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Prior medical therapy: History of failure, contraindication, or intolerance to at least one agent in relevant classes: proton pump inhibitor (PPI) (minimum 2 months) or swallowed topical corticosteroid (minimum 12 weeks)

inv-07: Prurigo nodularis - Initial Therapy

Covered when ALL of the following are met

Disease severity: Presence of ≥20 nodules for at least 3 months or WI‑NRS (Worst‑Itch Numeric Rating Scale) score ≥7, and underlying causes (e.g., drug‑induced or other medical conditions such as dermatillomania) excluded≥20 nodules for ≥3 months; WI‑NRS ≥7

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Prior topical/systemic therapy: History of failure or intolerance to at least one medium‑ to very‑high potency topical corticosteroid and other listed therapies as applicable: topical calcineurin inhibitor (minimum 3 weeks), topical vitamin D analogue (minimum 3 weeks), phototherapy (minimum 1 month), or systemic immunosuppressant (minimum 3 weeks)specified minimum trial durations

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Nemolizumab specific prior: For nemolizumab requests: trial of dupilumab must have been ineffective, contraindicated, or not tolerated (minimum trial of 24 weeks)

inv-08: COPD - Initial Therapy

Covered when ALL of the following are met

COPD objective measures: Documented lung function with percent predicted FEV1 between 30–70% measured within the last 12 months AND dyspnea score ≥2 on the Medical Research Council (MRC) dyspnea scaleFEV1 30–70%; MRC ≥2

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Eosinophil threshold: Absolute blood eosinophil count ≥300 cells/µL within the last 12 months≥300 cells/µL

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Maximal inhaled therapy: Patient is being treated with maximal inhaled therapy (ICS + LABA + LAMA) or double maintenance therapy (LABA + LAMA) if ICS is contraindicated

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Requests for prurigo nodularis do not qualify when the nodular disease is attributable to an identifiable underlying cause that would alter management. Specifically, prurigo nodularis that is drug-induced or caused by other medical conditions (for example, dermatillomania) is excluded from meeting the qualifying disease severity criteria for this form.

Prior authorization requests that are incomplete or lack required documentation may be administratively denied. Ensure the entire prior authorization form is completed and include supporting chart notes with required clinical information, a dated prescriber signature, and the prescriber specialty to avoid delays or denial.

Requests that do not meet the indication‑specific prior therapy or severity criteria described on the form (for example, required prior trials, minimum trial durations, or objective measures) also do not meet medical necessity under the form and may be denied.

Key Diagnostic and Laboratory Thresholds

inv-11: Blood eosinophil count for asthma — ≥150 cells/μL within last 12 months

ThresholdBlood eosinophil count ≥150 cells/μL within the last 12 months

PurposeDefines eosinophilic asthma phenotype for biologic eligibility

Timeframe for testAny documented peripheral blood eosinophil count within the prior 12 months is acceptable

inv-12: Blood eosinophil count for COPD — ≥300 cells/μL within last 12 months

ThresholdAbsolute blood eosinophil count ≥300 cells/μL within the last 12 months

ContextRequired for COPD phenotype assessment on the prior authorization form

DocumentationAny recorded peripheral eosinophil count from the prior 12 months may be used to meet criterion

inv-13: Eosinophilic esophagitis histology threshold — peak ≥15 eos/hpf (~60 eos/mm2)

Histology thresholdPeak ≥15 eosinophils per high-power field (≈60 eos/mm2) on esophageal biopsy

Clinical requirementSymptoms consistent with eosinophilic esophagitis must accompany the biopsy finding

Other causesOther causes of esophageal eosinophilia must be excluded per form instructions

inv-14: Prurigo nodularis nodule count — ≥20 nodules for at least 3 months

Nodule count and durationPresence of ≥20 nodules for at least 3 months

Alternate severity measureWorst-Itch Numeric Rating Scale (WI‑NRS) score ≥7 may also indicate qualifying severity

Exclusion of secondary causesUnderlying drug-induced or other medical causes (e.g., dermatillomania) must be excluded

inv-15: Topical/systemic trial minimum durations (examples) — topical corticosteroids ≥28 days; dupilumab examples 16–24 weeks as specified

Topical corticosteroidsMinimum trial of topical corticosteroids of at least 28 days (medium/moderate potency or greater)

Topical calcineurin/PDE‑4Trials of topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) or topical PDE‑4 (e.g., crisaborole) as specified on form

Biologic trial durations (example)For select agents, trial of dupilumab may be specified with minimum durations (e.g., 16 weeks for some indications; 24 weeks required prior to nemolizumab in PN)

What the Prescriber Must Provide

Prior Authorization

Prior Authorization Required

Prior authorization is required for IL-4/IL-13/IL-31 inhibitors. Use the Washington Prior Authorization Request Form for Cytokine and CAM Antagonists and fax the completed form to 866-940-7328. Allow at least 24 hours for review. If you have questions call 800-310-6826.

Complete the entire Washington Prior Authorization Request Form for Cytokine and CAM Antagonists (IL-4/IL-13/IL-31 inhibitors).
Fax completed form to 866-940-7328; allow at least 24 hours for review.
For questions call 800-310-6826.

Step Therapy

Document Preferred Product Trials for Non‑Preferred Requests

For non-preferred medication requests, document trials of preferred Cytokine and CAM medications listed on the Apple Health Preferred Drug List (AHPDL). For each preferred product trial include medication name and duration, and indicate if the medication was ineffective, contraindicated, or not tolerated. If preferred products were not tried, provide a clinical explanation.

If request is non-preferred, list each preferred medication trial and duration (AHPDL) and the outcome.
If preferred products were not tried, provide explanation why they are clinically inappropriate or contraindicated.

Documentation Required

Complete Form and Include Chart Notes

Complete the entire prior authorization form and include required chart notes with clinical information. Missing or incomplete documentation (including absent chart notes, missing prescriber signature, or missing prescriber specialty) may delay review or result in denial.

Attach chart notes that include: current weight with date, relevant diagnoses, dates and details of prior therapies and trials, and objective clinical response or stability documentation for continuation requests.
Ensure prescriber signature, prescriber specialty, and date are present on the request.

Documentation Required

Provide Objective Clinical Data

Provide objective clinical data as applicable to the diagnosis being treated. Include test results and measurements with dates to support medical necessity.

Weight with date (required).
Lung function: FEV1 or percent predicted FEV1 with date (for asthma/COPD).
Blood eosinophil counts with date(s) where applicable (e.g., asthma, COPD).
Relevant histology or biopsy reports (e.g., eosinophilic esophagitis) with dates.
Polyp or nodule counts, pruritus severity scores, disease severity scales (IGA, EASI, POEM), and other objective measures as applicable.

Denial Risk

Incomplete Requests May Be Delayed or Denied

Incomplete requests without required chart notes, prescriber signature, or prescriber specialty may be delayed or denied. Review the form checklist and attached documentation before submission to avoid administrative denials.

Chart notes are required with every request.
Prescriber signature, prescriber specialty, and date must be included.
Failure to provide complete documentation may result in delayed processing or denial.

OpenPayer

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

Coverage Criteria by Indication

Key Diagnostic and Laboratory Thresholds

What the Prescriber Must Provide

Form Purpose and Scope

Clinical Response and Severity Definitions