CurrentUnitedHealthcarePolicy N/A

Cytokine & CAM Antagonists: Oral PDE-4 inhibitors Washington Prior Authorization Request Form

This document is a Washington state prior authorization request form used by UnitedHealthcare for oral PDE-4 inhibitors (Cytokine & CAM Antagonists). It governs submission requirements and clinical information needed from providers requesting new or continuation therapy.

Policy Summary

PayerUnitedHealthcare

PolicyOral PDE-4 inhibitors prior authorization form (Washington)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form with chart notes, prescriber signature and specialty, diagnosis with ICD-10 code, prior medication history, and fax to 866-940-7328 allowing at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Washingtonjurisdiction

24 hoursminimum review time

866-940-7328submission fax

800-310-6826questions phone

Behcet's/Psoriasis/PsAdiagnosis sections

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Coverage Criteria

Diagnosis-specific coverage criteria

Coverage considered when required clinical criteria and documentation are provided for the specific diagnosis.

General requirements: Submit completed prior authorization form with chart notes, prescriber signature and specialty, diagnosis with ICD-10 code, and prior medication history; allow at least 24 hours for review.

Form-level requirements apply to all requests

Continuation of therapy: For continuation requests, documentation demonstrating disease stability or a positive clinical response must be submitted.

Applies to all diagnoses when continuation is indicated

Behcet's disease initial therapy criteria

Behcet's required manifestations: Patient has recurrent Behcet syndrome manifesting as oral ulcers of the mouth.
Question 7
Behcet's prior therapy trials: History of failure, contraindication, or intolerance to one or more of: topical corticosteroids (minimum trial 7 days); sucralfate mouthwash (minimum trial 7 days); colchicine (minimum trial 3 months); oral corticosteroids (minimum trial 1 month).
Question 8

Plaque psoriasis initial therapy criteria

Duration and distribution: Disease present >6 months AND affects ≥10% BSA or involves genitalia or affects face, ears, hands, or feet.
Questions 10-11
Baseline assessments (e.g., BSA, PASI, Psoriasis PGA, itch numeric rating scale) have been submitted.
Question 12
Prior therapy trials for plaque psoriasis: History of failure, contraindication, or intolerance to phototherapy (UVB or PUVA) [minimum 12 weeks] AND treatment with at least one non-Cytokine and CAM DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) [minimum 12 weeks].
Question 13

Psoriatic arthritis (PsA) initial therapy criteria

DMARD trial: Patient had treatment with at least one non-Cytokine and CAM DMARD that was ineffective, contraindicated, or not tolerated [minimum trial of 3 months].
Question 15
Disease activity: Provider documents presence of active, severe disease.
Question 16
Evidence of severe impact: At least one of: erosive disease; elevated CRP or ESR; long-term damage interfering with function (e.g., joint deformities, vision loss); major impairment of quality of life due to high disease activity or functionally limiting arthritis.
Question 17

The form requires an explanation when a non-preferred oral PDE-4 inhibitor is requested. Providers must document either prior trials of one or more preferred Cytokine & CAM medications on the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated, including medication name(s) and duration(s), or provide a clear rationale for why preferred products were not tried. The previous medication trials section on the form captures medication name, strength, directions, dates of therapy, and reason for discontinuation to support that justification.

Requests that do not include the diagnosis-specific minimums will be considered not medically necessary. For plaque psoriasis initial requests, the form requires documentation of ongoing disease >6 months, baseline assessments (e.g., BSA, PASI, PGA, or itch numeric rating scale), and failure/contraindication/intolerance to phototherapy (≥12 weeks) and at least one non-CAM DMARD (≥12 weeks). For Behcet's disease, the form requires confirmation of recurrent oral ulcers and minimum trials where applicable (topical corticosteroids ≥7 days; sucralfate mouthwash ≥7 days; colchicine ≥3 months; oral corticosteroids ≥1 month). For psoriatic arthritis, documentation must show treatment with at least one non-CAM DMARD (≥3 months), provider assessment of active/severe disease, and presence of erosive disease, elevated CRP/ESR, long-term damage, or major impairment of quality of life as applicable. Continuation requests for any diagnosis must include chart documentation demonstrating disease stability or positive clinical response.

Coding and Diagnostic Data

Diagnosis codes (form field)ICD-10

ICD-10 CODE

Field on form to supply the patient's ICD-10 diagnosis code

Minimum medication trial durations and examples

Topical corticosteroidsMinimum trial of 7 days (e.g., triamcinolone)

Sucralfate mouthwashMinimum trial of 7 days

ColchicineMinimum trial of 3 months

Oral corticosteroidsMinimum trial of 1 month (e.g., prednisone)

PhototherapyMinimum trial of 12 weeks (UVB or PUVA)

Non-Cytokine/CAM DMARDsMinimum trial of 12 weeks for plaque psoriasis; minimum trial of 3 months for psoriatic arthritis (e.g., methotrexate, cyclosporine, acitretin, azathioprine)

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Complete and fax the full Prior Authorization Request Form to 866-940-7328 and allow at least 24 hours for review. For questions call 800-310-6826. Incomplete submissions may delay review.

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

Step Therapy

Step therapy / Preferred product trials

If the request is for a non-preferred product, document trials of one or more preferred Cytokine and CAM medications from the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated, or provide an explanation why preferred products were not tried.

List each preferred medication trial and duration
Or explain why preferred products were not tried

Definitions and Baseline Assessment Requirements

Oral phosphodiesterase-4 (PDE-4) inhibitors are indicated in the form for inflammatory dermatologic and rheumatologic conditions including plaque psoriasis, psoriatic arthritis, and Behcet's disease. The prior authorization form collects diagnosis-specific clinical criteria, baseline assessments, and prior treatment history to assess medical necessity for initiation or continuation of therapy; for continuation requests the form specifically asks whether there is documentation demonstrating disease stability or a positive clinical response.

Baseline assessments for psoriasis (BSA, PASI, PGA examples)

Body Surface Area (BSA)Example baseline assessment requested on form to quantify percent body involvement

Psoriasis Area and Severity Index (PASI)Example baseline assessment requested on form to quantify disease severity

Psoriasis Physician's Global Assessment (PGA)Example baseline assessment requested on form for provider global severity rating

Itch numeric rating scaleExample patient-reported baseline assessment requested on form

Policy Summary

PayerUnitedHealthcare

PolicyOral PDE-4 inhibitors prior authorization form (Washington)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Documentation Required

Chart notes and continuation documentation required

Chart notes must be included with every request. For continuation requests, submit documentation demonstrating disease stability or a positive clinical response (examples: improvement in oral lesions, BSA, PASI, PGA, joint pain/swelling reduction, visual acuity, decreased corticosteroid use). Missing chart notes, missing prescriber signature, or missing prescriber specialty may result in denial or delay.

Include relevant objective baseline assessments when applicable (e.g., BSA, PASI, PGA, CRP/ESR)
For continuation, show clinical benefit or stability (specific measures per diagnosis)
Include prescriber signature, prescriber specialty, and date

Documentation Required

Required prescribing details and prior medication trials

Provide the diagnosis with the specific ICD-10 code and complete the Medical Information section. Include prior medication trial details: medication names, strengths, directions, dates of therapy, and reasons for discontinuation.

Diagnosis with ICD-10 code (be specific)
Prior medication name, strength, directions, dates of therapy, and reason for discontinuation

Denial Risk

Denial risk for missing documentation or required trials

Failure to document required prior medication trials, baseline assessments, or the items listed above (diagnosis with ICD-10, chart notes, prescriber signature/specialty/date) may result in denial or processing delays.

Denial risk if prior medication trials for diagnosis-specific requirements are not documented
Denial or delay if baseline assessments (e.g., BSA, PASI, PASI, CRP/ESR) or continuation response measures are missing

Behcet's disease trial requirements (topical corticosteroids, sucralfate, colchicine, oral corticosteroids durations)

Topical corticosteroidsMinimum trial of 7 days (e.g., triamcinolone)

Sucralfate mouthwashMinimum trial of 7 days

ColchicineMinimum trial of 3 months

Oral corticosteroidsMinimum trial of 1 month (e.g., prednisone)

Psoriatic arthritis DMARD requirement (non-CAM DMARD trial ≥3 months)

Non-Cytokine and CAM DMARD trialAt least one non-Cytokine and CAM DMARD that was ineffective, contraindicated, or not tolerated with minimum trial of 3 months

Examples of non-Cytokine/CAM DMARDse.g., methotrexate, cyclosporine, acitretin, azathioprine (as listed on form)

Documentation of ineffectiveness/intoleranceForm requires indication that prior DMARD was ineffective, contraindicated, or not tolerated