CurrentUnitedHealthcarePolicy N/A

Wa Cytokine Cam Jak Inhibitors Pa Form

A Washington state prior authorization request form used by UnitedHealthcare (Apple Health) for Janus Associated Kinase (JAK) inhibitors within the Cytokine and CAM antagonists class. The form collects patient, prescriber, pharmacy and clinical information to support initial or continuation authorization across multiple labeled and off-label diagnoses with disease-specific trial and response criteria.

Policy Summary

PayerUnitedHealthcare

PolicyWa Cytokine Cam Jak Inhibitors Pa Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the fully completed prior authorization form and required chart notes to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material changes — has_material_change = false

13Diagnoses covered by form

MultipleRequired baseline or response measures

24 hoursMinimum review turnaround (allow at least)

Coverage Summary

Scope: This is a Washington state prior authorization request form used by UnitedHealthcare (Apple Health) for Janus Associated Kinase (JAK) inhibitors within the Cytokine and CAM Antagonists class. The form collects patient, prescriber, pharmacy and clinical information to support initial or continuation authorization across multiple labeled and off-label diagnoses including dermatologic, rheumatologic, and gastrointestinal conditions.

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General Prior Authorization Requirements

General prior authorization requirements

Request form must be completed and chart notes submitted; allow at least 24 hours for review.

ALL of the following

Complete entire form and fax to 866-940-7328 or call 800-310-6826 for questions
Chart notes are required with this request
Indicate whether request is for continuation of therapy
Indicate prescriber specialty or consultation with specialist (Allergist, Dermatologist, Gastroenterologist, Immunologist, Rheumatologist, Other)
Indicate if medication will be used in combination with another Cytokine and CAM medication
If request is for non-preferred product, document trial, intolerance, or contraindication to preferred Cytokine and CAM medications on the Apple Health Preferred Drug List (AHPDL) or explain why not tried
Provide patient weight (kg) and date taken
Provide prescriber signature, prescriber specialty, and date

Prior Authorization

Submit completed PA form and chart notes

Fax the fully completed prior authorization form and required chart notes to 866-940-7328; allow at least 24 hours for review.

800-310-6826

Documentation Required

Document prior therapy trials and durations

For non-preferred medications, document trials of preferred agents (medication names and duration). For disease-specific criteria, document prior therapies with the specified minimum trial durations and reasons for contraindication or intolerance if applicable.

Documentation Required

Provide baseline and follow-up disease activity measures

Submit baseline assessments (examples include SALT, BASDAI, ASDAS, BSA, PASI, PGA, DAS28, EASI, CDAI, endoscopy results) and for continuation requests provide documentation of positive clinical response or disease stability using the specified measures on the form.

SALT
BASDAI
ASDAS
BSA
PASI
PGA
DAS28
EASI
CDAI
Endoscopy results

Denial Risk

Requests lacking required trials or documentation may be denied

If minimum prior therapy trials, required specialist consultation, chart notes, or evidence of response or disease stability are not submitted as specified for the selected diagnosis, the request risks denial.

Diagnosis-specific Coverage Criteria

Diagnosis-specific coverage criteria

Coverage considered when ALL of the following disease-specific criteria are met for the selected diagnosis.

One of the following diagnoses selected

ALL of the following
- Current episode lasting more than 6 months> 6 months
- ≥50% scalp hair loss (Severity of Alopecia Tool [SALT] score >50%)SALT score >50%
- History of failure, contraindication, or intolerance to any 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)
- Continuation: Documentation demonstrating positive clinical response (improvement in SALT score) is submitted
ALL of the following
- High disease activity indicated by BASDAI ≥ 4 OR ASDAS ≥ 2.1BASDAI ≥ 4 OR ASDAS ≥ 2.1
  One of BASDAI ≥4 or ASDAS ≥2.1 must be present
- Treatment with at least two different NSAIDs ineffective, contraindicated, or not tolerated (minimum trial 4 weeks)minimum trial 4 weeks
- Disease manifestation: axial disease OR peripheral arthritis
- Treatment with at least one non-Cytokine and CAM DMARD ineffective, contraindicated, or not tolerated (minimum trial 3 months)minimum trial 3 months
ALL of the following
- Disease severity: BSA involvement at least 10% (and does not exceed 20% option listed) OR involvement of sensitive areas OR baseline severity scale supporting moderate to severe chronic atopic dermatitis (e.g., IGA ≥3, EASI, POEM)BSA ≥ 10%
  form notes also 'does not exceed 20%'
- Functional impairment due to atopic dermatitis (ADLs, skin infections, sleep disturbances) may be present
- History of failure to topical corticosteroids (medium/moderate potency) OR topical calcineurin inhibitors OR topical PDE-4 inhibitors each with minimum trial of 28 days, unless contraindicated or clinically inappropriateminimum trial 28 days
- Continuation: Documentation demonstrating disease stability or positive clinical response, defined by any of: ≥20% reduction in BSA from baseline; achieved/maintained clear or minimal disease (IGA 0 or 1); ≥50% decrease in EASI; improvement in functional impairment
ALL of the following
- Treatment with conventional therapies ineffective, contraindicated, or not tolerated: oral corticosteroids (short-term to induce remission) and/or immunomodulatory agent (e.g., methotrexate, azathioprine, 6-MP) with minimum trial 12 weeksminimum trial 12 weeks
- Documentation of high-risk disease (examples: symptoms despite conventional therapy, obstruction, abscess, stricture, phlegmon, fistulas, resection, extensive bowel involvement, early onset, growth retardation, CDAI > 450, Harvey-Bradshaw index > 7)
- Continuation: Documentation demonstrating disease stability or positive clinical response (improvement in endoscopic activity, taper/discontinuation of corticosteroids, reduction in liquid stools, decreased abdominal pain, decreased CDAI or Harvey-Bradshaw index) is submitted
ALL of the following
- Ongoing disease > 6 months> 6 months
- Disease affects ≥10% BSA OR affects face/ears/hands/feet/genitaliaBSA ≥ 10%
- Baseline assessments submitted (e.g., BSA, PASI, PGA, itch NRS)
- History of failure, contraindication, or intolerance to phototherapy (UVB or PUVA) minimum trial 12 weeks AND/or at least one non-Cytokine and CAM DMARD (minimum trial 12 weeks)minimum trial 12 weeks
- Continuation:
ALL of the following
- Treatment with at least one non-Cytokine and CAM DMARD ineffective unless contraindicated or not tolerated (minimum trial 3 months)minimum trial 3 months
- Continuation: Documentation demonstrating disease stability or positive clinical response (improvement in joint pain, swelling, ADLs, reduction in flares) is submitted
ALL of the following
- Treatment with at least one non-Cytokine and CAM DMARD ineffective, contraindicated, or not tolerated (minimum trial 3 months)minimum trial 3 months
- Presence of active, severe disease by provider assessment
- Presence of any of: erosive disease; elevated CRP or ESR; long-term damage interfering with function; major impairment of quality of life due to high disease activity or functionally limiting arthritis
- Continuation: Documentation demonstrating disease stability or positive clinical response (improvement in joint pain, swelling, ADLs, reduction in flares) is submitted
ALL of the following
- Baseline assessments submitted (e.g., DAS28-CRP/ESR, SDAI, CDAI, RAPID3, PAS II)
- Treatment with at least one non-Cytokine and CAM DMARD ineffective unless contraindicated or not tolerated (minimum trial 3 months)minimum trial 3 months
- Continuation: Documentation demonstrating disease stability or positive clinical response (improvement in DAS28, SDAI, CDAI, RAPID3, PAS II) is submitted
ALL of the following
- Baseline assessments submitted (e.g., stool frequency, endoscopy results, rectal bleeding, disease activity scoring tool)
- Treatment with conventional therapy (e.g., systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) ineffective unless contraindicated or not tolerated (minimum trial 12 weeks)minimum trial 12 weeks
- Continuation: Documentation demonstrating disease stability or positive clinical response (decreased stool frequency, decreased rectal bleeding, improved endoscopic activity, tapering/discontinuation of corticosteroids, improvement on disease activity scoring tool) is submitted
ALL of the following
- Chronic vitiligo for more than 3 months> 3 months
- Total BSA involvement 10% or lessBSA ≤ 10%
- Treatment with phototherapy OR topical calcineurin inhibitors OR medium to high potency topical corticosteroids ineffective or not tolerated with minimum trial of 2 monthsminimum trial 2 months
- Continuation: Documentation demonstrating positive clinical response (improvement in F-VASI and/or T-VASI or reduction in total BSA) is submitted
ALL of the following
- Documentation that BSA involvement does not exceed 20%BSA ≤ 20%
- Functional impairment due to chronic hand eczema may include ADLs, skin infections, sleep disturbances
- History of failure to topical corticosteroids (medium/moderate potency), topical calcineurin inhibitors, topical PDE-4 inhibitors each minimum trial 28 days unless contraindicatedminimum trial 28 days
- Treatment with dupilumab (Dupixent) ineffective, contraindicated, or not tolerated (minimum trial 16 weeks)minimum trial 16 weeks

Definitions and Thresholds

Background and form purpose: The prior authorization form standardizes collection of clinical details for JAK inhibitors to determine medical necessity across multiple diagnoses. It requires completion of the entire form, fax submission to 866-940-7328, and allows at least 24 hours for review.

What the form collects: patient identifiers and demographics, pharmacy and prescriber information, medication name/strength/directions/quantity, whether the request is for continuation of therapy, prescriber specialty or consultation (options include Allergist, Dermatologist, Gastroenterologist, Immunologist, Rheumatologist, Other), whether the medication will be used in combination with another Cytokine and CAM agent, and patient weight with date taken.

Prior therapy requirements and minimum trial durations: For non-preferred products, the form requests documentation of trials of preferred Cytokine and CAM medications (AHPDL) including medication names and durations. Disease-specific prior therapy requirements and minimum trials are collected on diagnosis-specific sections (examples): Alopecia areata — trials of high-potency topical corticosteroids, intralesional corticosteroids, or systemic therapy each with a minimum trial of 6 weeks; Ankylosing spondylitis — two different NSAIDs (minimum 4 weeks) and at least one non-Cytokine DMARD (3 months); Atopic dermatitis — topical agents each with minimum 28-day trials; Plaque psoriasis — phototherapy 12 weeks and at least one non-CAM DMARD 12 weeks; Crohn's disease and ulcerative colitis — conventional therapy or immunomodulator trials with minimum 12 weeks; rheumatologic DMARD trials generally 3 months; chronic hand eczema — trial of dupilumab 16 weeks; vitiligo — prior therapies with minimum 2 months.

Baseline assessments and documentation: The form requests baseline disease activity measures where applicable (examples: SALT for alopecia, BASDAI or ASDAS for axial disease, BSA/PASI/IGA/EASI for dermatologic indications, DAS28/SDAI/CDAI/RAPID3/PAS II for RA, CDAI/Harvey-Bradshaw/Crohn’s endoscopy results for Crohn’s, stool frequency/rectal bleeding/endoscopy for UC, F-VASI/T-VASI for vitiligo).

Documentation for continuation: For continuation requests the form requires documentation of clinical response or disease stability using specified measures (e.g., improvement in SALT; decrease in BASDAI or ASDAS; ≥20% reduction in BSA, IGA 0–1, or ≥50% decrease in EASI; improvement in endoscopic findings or disease activity indices; improvements in joint symptoms or functional measures).

Other documentation requirements and signature: The form emphasizes that chart notes are required with the request and requires prescriber signature, prescriber specialty, and date. It also instructs documentation of reasons trials were not attempted when applicable (intolerance, contraindication, or clinical inappropriateness).

Denial risk: The form notifies that requests lacking minimum prior therapy trials, specialist consultation, chart notes, or evidence of response/stability as specified may be denied.

Key thresholds

Definitions

OpenPayer

Wa Cytokine Cam Jak Inhibitors Pa Form

Coverage Summary

General Prior Authorization Requirements

Diagnosis-specific Coverage Criteria

Definitions and Thresholds

Coding

Revision History