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 governing coverage review for oral PDE‑4 inhibitor therapies within UnitedHealthcare (Apple Health) for indications such as Behcet's disease, plaque psoriasis, and psoriatic arthritis; it affects prescribing providers seeking authorization and continuation of therapy.

Policy Summary

PayerUnitedHealthcare

PolicyOral PDE-4 inhibitors prior authorization (Washington)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary diagnoses addressed

24+form fields/questions

24 hoursminimum review time

866-940-7328submission fax

Coverage Criteria for Oral PDE-4 Inhibitors

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Initial and continuation coverage criteria

Covered when ALL of the following are met (assessment and documentation vary by diagnosis):

Form submission and documentation: Completed prior authorization form faxed to 866-940-7328 with required chart notes, prescriber signature, prescriber specialty and date; allow at least 24 hours for review.

Diagnosis selection: Patient has a listed diagnosis (Behcet's disease, plaque psoriasis, or psoriatic arthritis) and the corresponding diagnosis-specific section(s) on the form are completed.

Combination therapy disclosure: The form indicates whether the requested medication will be used in combination with another Cytokine and CAM medication; combination use must be disclosed on the form.

Preferred drug trial documentation (when applicable): If the requested medication is non-preferred, documentation of trial(s) of preferred Cytokine & CAM medications on the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated must be provided, including medication names and duration of each trial.

Behcet's disease specific

Recurrent Behcet syndrome manifesting as oral ulcers is present.
History of failure, contraindication, or intolerance to one or more of: topical corticosteroids (e.g., triamcinolone) with minimum trial of 7 days; sucralfate mouthwash with minimum trial of 7 days; colchicine with minimum trial of 3 months; or oral corticosteroids (e.g., prednisone) with minimum trial of 1 month.
For continuation requests, documentation demonstrating disease stability or a positive clinical response (examples: improvement in oral lesions, vitreous haze, visual acuity, corticosteroid usage) has been submitted.

Plaque psoriasis specific

Presence of ongoing disease for greater than 6 months.
Severity/location criteria: Either disease affects at least 10% body surface area or involves face/ears/hands/feet/genitalia.
Baseline assessments have been submitted (examples: BSA, PASI, Psoriasis PGA, itch numeric rating scale).
History of failure, contraindication, or intolerance to phototherapy (UVB or PUVA) with a minimum trial of 12 weeks and to at least one non-Cytokine and CAM DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) with a minimum trial of 12 weeks.
For continuation requests, documentation demonstrating disease stability or a positive clinical response (examples: improvement in BSA, PASI, Psoriasis PGA, itch numeric rating scale) has been submitted.

Psoriatic arthritis specific

History of treatment with at least one non-Cytokine and CAM DMARD that was ineffective, contraindicated, or not tolerated (minimum trial of 3 months).
Active or severe disease as indicated by provider assessment, and/or presence of disease features such as erosive disease, elevated CRP/ESR, long-term damage interfering with function, or major impairment of quality of life due to high disease activity.
For continuation requests, documentation demonstrating disease stability or a positive clinical response (examples: improvement in joint pain, swelling, activities of daily living, reduction in disease flares) has been submitted.

General required documentation: Chart notes and prescriber signature, specialty, and date are included with the request; missing required documentation may result in denial or delay.

The form asks whether the requested medication will be used in combination with another Cytokine & CAM medication and requires that combination use be indicated on the prior authorization. Providers should disclose concurrent combination therapy on the form; failure to indicate combination use may affect review or coverage determination. The form does not implicitly authorize unlisted combinations — concurrent use must be documented and justified on the submission.

Requests may be considered incomplete or not medically necessary if they lack documentation of required prior medication trials, minimum trial durations, or baseline assessments. Section D requires listing previous medication trials with dates and reasons for failure, and question 4 on the clinical section requires documentation of trials of preferred Cytokine & CAM agents (or an explanation why preferred products were not tried). Ensure the form includes chart notes with trial durations and reasons for discontinuation to avoid delays or denial.

Diagnosis and Related Coding

Diagnosis codesICD-10

ICD-10 CODE

Field for specific diagnosis ICD-10 code

Ongoing disease duration (inv-05)

Ongoing disease duration requirementPatient must have presence of ongoing disease for greater than 6 months.

Assessment checkboxForm includes a yes/no question confirming ongoing disease >6 months (Question 10).

Applies to which diagnosisSpecifically referenced in plaque psoriasis criteria; used as an eligibility threshold for that diagnosis section.

Minimum prior therapy trial durations (inv-06)

Topical corticosteroids (Behcet's)Minimum trial of 7 days (e.g., triamcinolone).

Sucralfate mouthwash (Behcet's)Minimum trial of 7 days.

Colchicine (Behcet's)Minimum trial of 3 months.

Oral corticosteroids (Behcet's)Minimum trial of 1 month (e.g., prednisone).

Phototherapy (Plaque psoriasis)Minimum trial of 12 weeks (UVB or PUVA).

Non-Cytokine/CAM DMARDs (Plaque psoriasis)Minimum trial of 12 weeks (e.g., methotrexate, cyclosporine, acitretin, azathioprine).

Non-Cytokine/CAM DMARD (Psoriatic arthritis)Minimum trial of 3 months for at least one DMARD prior to therapy (Question 15).

Submission, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Request Form: Complete this entire form and fax to 866-940-7328. Allow at least 24 hours for review. If you have questions, call 800-310-6826. Failure to submit the completed form may delay or result in denial of the request.

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

Documentation Required

Preferred Drug Trial Documentation

If the requested product is non‑preferred, document trials of preferred Cytokine & CAM medications from the Apple Health Preferred Drug List (AHPDL). For each preferred agent tried include medication name and duration of trial, and state whether treatment was ineffective, contraindicated, or not tolerated. If no preferred product was tried, provide a clinical explanation why preferred alternatives would not meet the patient’s needs.

List preferred medication trials with dates/duration and reason for failure/intolerance
If no preferred trial, provide clinical justification referencing AHPDL

Documentation Required

Required Clinical Documentation

Chart notes are REQUIRED with this request. For continuation of therapy, include documentation demonstrating disease stability or a positive clinical response. Include documentation of the clinical indication, relevant history, prior medication trials (Section D), and the rationale if prescribing a non‑preferred agent.

Include chart notes showing baseline and follow‑up assessments or evidence of response/stability for continuation requests
Provide prior medication trial details (names, strengths, directions, dates, reasons for failure)
Document current weight and date (kg) when requested

Denial Risk

Missing Documentation May Delay or Deny Request

Missing required information may result in denial or delay. Ensure the request includes the prescriber signature, prescriber specialty, date, and completed Sections D and E (previous medication trials and explanation why preferred medications are not appropriate).

Prescriber signature required
Prescriber specialty required
Request date required
Completed Section D (Previous Medication Trials) and Section E (explanation)

OpenPayer

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

Coverage Criteria for Oral PDE-4 Inhibitors

Diagnosis and Related Coding

Submission, Documentation, and Provider Requirements

Background and Clinical Context

Definitions and Continuation Criteria