CurrentUnitedHealthcarePolicy N/A

Integrin receptor antagonist prior authorization (Cytokine & CAM Antagonists) — Washington prior authorization request form and clinical criteria checklist

This document is a Washington-specific prior authorization request form and clinical criteria checklist for integrin receptor antagonists and related Cytokine & CAM agents, used by prescribers and pharmacies to request coverage for listed indications.

Policy Summary

PayerUnitedHealthcare

PolicyIntegrin receptor antagonist prior authorization (Cytokine & CAM Antagonists) — Washington prior authorization request form and clinical criteria checklist

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete the prior authorization form and include chart notes, prescriber signature and specialty, and supporting clinical documentation when submitting requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40form lines/items

12indications listed

24explicit thresholds/durations

Coverage and Medical Necessity Criteria

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.

General submission requirements: Complete prior authorization form, include chart notes, prescriber signature and specialty, and baseline assessments as applicable.

see chunks 0 and 14

Prior therapy requirements (example: rheumatoid/psoriatic/polyarticular JIA): At least one non-Cytokine and CAM DMARD trial that was ineffective, contraindicated, or not tolerated (minimum 3 months) unless all are contraindicated.3 months

chunks 9,10,11

Axial spondyloarthritis/Ankylosing Spondylitis criteria: High disease activity (BASDAI >=4 or ASDAS >=2.1); trial of at least two different NSAIDs (minimum 4 weeks); disease manifestation documented (axial or peripheral); prior non-Cytokine and CAM DMARD trial (minimum 3 months).BASDAI >=4 OR ASDAS >=2.1; NSAID trial 4 weeks; DMARD 3 months

chunk 3

Atopic dermatitis criteria: Severe disease defined by BSA >=10% or involvement of sensitive areas or IGA >=3 (or similar severity scale); failure of topical therapies (each minimum 28 days) and trial of dupilumab for 16 weeks unless contraindicated.BSA >=10%; topical trials 28 days each; dupilumab 16 weeks

chunks 4 and 5

Alopecia areata criteria: Current episode >6 months AND SALT score >50% (>=50% scalp hair loss) AND failure, intolerance, or contraindication to high-potency topical corticosteroids, intralesional corticosteroids, or systemic therapy (each minimum trial of 6 weeks).>6 months; SALT >50%; trials 6 weeks

chunk 2

Inflammatory bowel disease (Crohn's/Ulcerative Colitis) criteria: Failure, intolerance, or contraindication to conventional therapies (e.g., systemic corticosteroids, immunomodulators) with minimum trial durations (immunomodulators minimum 12 weeks); documentation of high‑risk features for Crohn's (examples include obstruction, abscess, fistula, extensive bowel involvement, early onset, growth retardation, CDAI >450, Harvey‑Bradshaw >7) or baseline assessments for UC (e.g., stool frequency, endoscopy, rectal bleeding).Immunomodulator 12 weeks; CDAI >450 or Harvey-Bradshaw >7 as high-risk examples

chunks 6 and 13

Plaque psoriasis criteria: Ongoing disease >6 months AND disease affecting >=10% BSA or critical areas (face, hands, feet, genitalia); baseline assessments submitted; prior phototherapy (minimum 12 weeks) and at least one non-Cytokine and CAM DMARD trial (minimum 12 weeks) unless contraindicated.>6 months; BSA >=10%; phototherapy 12 weeks; DMARD 12 weeks

chunks 7 and 8

Continuation therapy

Continuation of therapy covered when ALL of the following are met:

Documentation of response: Documentation submitted demonstrating disease stability or positive clinical response using disease‑specific measures (examples by indication: decrease in BASDAI/ASDAS for axial disease; reduction in BSA/PASI/IGA/EASI for dermatologic disease; improvement in CDAI/Harvey‑Bradshaw for Crohn's; improvement in DAS28/SDAI/CDAI/RAPID3 for RA and related arthritides).varies by indication; see form

chunks 2,3,5,6,8,10,12,13

Prescriber verification: Request indicates whether therapy is a continuation and whether the prescriber is the listed specialist or a consulting specialist (e.g., allergist, dermatologist, gastroenterologist, immunologist, rheumatologist).

chunk 0

The form itself does not list standalone exclusions; instead it requires specific documentation and prior-therapy trials as a condition of coverage. In practice this means requests that do not include the completed prior authorization form, required prescriber signature and specialty, chart notes, baseline assessments, or evidence of the indicated prior therapy trials will be functionally excluded from coverage because the form cannot be approved without those items. See the form submission instructions and required documentation fields for details.

Use of an integrin receptor antagonist without meeting the indicated prior-therapy trials, disease severity thresholds, or providing objective baseline assessments and supporting chart notes is addressed by the form as not meeting medical necessity. Examples include absence of required minimum trials (e.g., ≥6-week topical/systemic trials for alopecia areata, ≥4-week NSAID trials or ≥3-month DMARD trials for spondyloarthritis, ≥12-week immunomodulator trials for Crohn’s/UC, or failure of topical therapies and a 16‑week dupilumab trial for atopic dermatitis) or failure to submit baseline measures (e.g., SALT, BASDAI/ASDAS, CDAI/Harvey‑Bradshaw, BSA/IGA). Requests lacking those elements risk being considered not medically necessary per the form.

Clinical Thresholds and Key Measures

SALT score — severe alopecia areata thresholds

SALT score threshold>50% (Severity of Alopecia Tool [SALT] score >50% indicating ≥50% scalp hair loss)

Current episode duration requirementCurrent episode lasting more than 6 months

Required prior topical/intralesional/systemic trialsMinimum trial of 6 weeks each for high‑potency topical corticosteroids, intralesional corticosteroids, or systemic therapy (if applicable)

BASDAI — high disease activity threshold (axial spondyloarthritis)

BASDAI thresholdBASDAI score of at least 4

Associated requirementsDocument trial of at least two different NSAIDs (minimum 4 weeks) and at least one non‑Cytokine/CAM DMARD trial (minimum 3 months)

Use in continuationFor continuation, submit documentation demonstrating decrease in BASDAI or ASDAS score

ASDAS — high disease activity threshold (axial spondyloarthritis)

ASDAS thresholdASDAS score of at least 2.1

Associated requirementsDocument trial of at least two different NSAIDs (minimum 4 weeks) and at least one non‑Cytokine/CAM DMARD trial (minimum 3 months)

Use in continuationFor continuation, submit documentation demonstrating decrease in ASDAS or BASDAI score

Atopic dermatitis BSA — severe disease threshold

Atopic dermatitis BSA thresholdBody surface area (BSA) involvement of at least 10%

Alternate severity indicatorsInvolvement of sensitive areas (hands, feet, face, neck, genitalia, intertriginous) or severe scores on IGA, EASI, POEM, etc.

Functional impairment examplesImpairment in ADLs, skin infections, or sleep disturbances may support severity

Dupilumab trial duration — required trial length

Dupilumab trial duration requiredMinimum trial of 16 weeks (dupilumab ineffective, contraindicated, or not tolerated)

Topical therapy trial minimumsTopical therapies (medium/moderate potency corticosteroids, calcineurin inhibitors, PDE‑4 inhibitors) minimum trial of 28 days each before escalation unless contraindicated

Continuation documentationFor continuation, submit documentation demonstrating disease stability or specified clinical response (e.g., ≥20% reduction in BSA, IGA 0–1, ≥50% decrease in EASI)

Conventional therapy DMARD trial duration (IBD: Crohn's/Ulcerative Colitis)

Conventional therapy DMARD trial duration (IBD)Immunomodulatory agent minimum trial of 12 weeks (e.g., methotrexate, azathioprine, 6‑mercaptopurine)

Systemic steroid useShort‑term oral corticosteroids may be used to induce remission; document prior use and response

Continuation documentation for IBDFor continuation, submit objective improvement (endoscopy, stool frequency, steroid taper, CDAI/Harvey‑Bradshaw improvement)

Non‑Cytokine/CAM DMARD trial duration — arthritides

Non‑Cytokine/CAM DMARD trial duration (arthritides)Minimum trial of 3 months for at least one non‑Cytokine and CAM DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine)

Applies to multiple diagnosesRequired for polyarticular JIA, psoriatic arthritis, rheumatoid arthritis, and similar indications unless all are contraindicated or not tolerated

Continuation requirementFor continuation, submit documentation demonstrating disease stability or positive clinical response (relevant joint scores or functional improvement)

Phototherapy trial duration for psoriasis

Phototherapy trial duration for psoriasisMinimum trial of 12 weeks (UVB or PUVA) before escalation to Cytokine & CAM agents unless contraindicated)

Non‑Cytokine/CAM DMARD requirement for psoriasisAt least one non‑Cytokine and CAM DMARD trial (e.g., methotrexate, cyclosporine, acitretin, azathioprine) minimum 12 weeks

Continuation documentationFor continuation, submit documentation demonstrating improvement in BSA, PSAI, Psoriasis PGA, or itch numeric rating scale

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for all integrin receptor antagonist medications in the Cytokine & CAM Antagonists class. Complete and submit the Prior Authorization Request Form in full; incomplete forms may delay review. Allow at least 24 hours for review.

Fax the completed form to 866-940-7328.
If you have questions call 800-310-6826.
This form may contain multiple pages — complete all pages to avoid delays.

Step Therapy

Preferred Product and Conventional Therapy Trials

Document trials of preferred Cytokine & CAM medications from the Apple Health Preferred Drug List (AHPDL) when the request is for a non-preferred product. If preferred products were not tried, provide clinical rationale why they were ineffective, contraindicated, or not tolerated.

If non-preferred, list each preferred medication and duration of trial on the form.
If no preferred product trial, explain why preferred product(s) were not tried.

Documentation Required

Required Documentation

Chart notes are required with every prior authorization request. Include documentation of diagnosis, prior medication trials (with durations), weight and date taken, prescriber specialty and signature, and for continuation requests provide objective evidence of disease stability or positive clinical response.

Include chart notes showing trials of topical therapies, phototherapy, or non-Cytokine DMARDs when applicable (minimum trials specified on form).
For atopic dermatitis continuation: document reduction in BSA ≥20%, IGA 0–1, ≥50% decrease in EASI, or functional improvement.
For other indications, include documentation of failure, contraindication, or intolerance to listed prior therapies and any required minimum trial durations.

Note

Submission Instructions

Complete the entire Prior Authorization Request Form and fax it with all supporting documentation (chart notes, prior trial details, weight/date, prescriber signature) to the fax number below. Missing attachments or incomplete responses may result in denial or delay.

Fax: 866-940-7328
Questions: 800-310-6826
Attach chart notes, prior therapy trial documentation, and prescriber signature/specialty.

Background and Clinical Context

Integrin receptor antagonists are targeted therapies used across multiple immune‑mediated diseases captured on this Washington prior authorization form, including inflammatory bowel disease (Crohn’s disease and ulcerative colitis), spondyloarthritis/ankylosing spondylitis, plaque psoriasis, atopic dermatitis, alopecia areata, and several arthritides. The form collects disease‑specific severity measures (for example SALT for alopecia areata, BASDAI/ASDAS for axial disease, CDAI/Harvey‑Bradshaw or endoscopic findings for Crohn’s, and BSA/IGA/EASI for atopic dermatitis), documents prior conventional therapy and DMARD trials with defined minimum durations, and requires chart notes and prescriber specialty to establish medical necessity for initiation or continuation of these agents.

Defined Clinical Terms and Thresholds

High disease activity — axial spondyloarthritis / Ankylosing Spondylitis

Definition of high disease activityBASDAI score ≥4 OR ASDAS score ≥2.1

Additional requirementsDocument trial of at least two different NSAIDs (minimum 4 weeks) and at least one non‑Cytokine/CAM DMARD trial (minimum 3 months)

Continuation documentationFor continuation, provide documentation demonstrating a decrease in BASDAI or ASDAS score

Severe alopecia areata — definition

Severe alopecia areata definitionCurrent episode >6 months AND SALT score >50% (≥50% scalp hair loss)

Required prior therapy trialsDocumented failure, contraindication, or intolerance to high‑potency topical corticosteroids, intralesional corticosteroids, or systemic therapy (minimum trials of 6 weeks)

Continuation documentationFor continuation, submit documentation demonstrating a positive clinical response

Severe atopic dermatitis — definition and therapy failures

Severe atopic dermatitis definitionBSA ≥10% OR involvement of sensitive areas OR severe chronic disease by IGA ≥3, EASI, POEM, etc., and failure of topical therapies

Dupilumab requirementDupilumab trial of 16 weeks required if applicable (ineffective, contraindicated, or not tolerated)

Topical therapy minimumsTopical corticosteroids, calcineurin inhibitors, or PDE‑4 inhibitors should have minimum trials (e.g., 28 days each) unless contraindicated