UnitedHealthcare TNF Inhibitor Prior Auth | OpenPayer

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UnitedHealthcare TNF Inhibitor Prior Auth | OpenPayer

Alopecia areata — Initial and Continuation

Covered when ALL of the following are met

Alopecia initial: Patient's current episode lasting >6 months; SALT score >50%; history of failure, contraindication, or intolerance to high‑potency topical corticosteroids (minimum trial 6 weeks), intralesional corticosteroids (minimum trial 6 weeks), or systemic therapy (e.g., oral corticosteroids, methotrexate, cyclosporine) (minimum trial 6 weeks)SALT >50%

For continuation, documentation of a positive clinical response must be submitted

Ankylosing Spondylitis / Non-radiographic axial spondyloarthritis

Covered when ALL of the following are met

Axial spondyloarthritis initial: High disease activity indicated by BASDAI ≥4 OR ASDAS ≥2.1; trial of at least two different NSAIDs (minimum trial 4 weeks each) that were ineffective, not tolerated, or contraindicated; disease manifested as axial disease or peripheral arthritis; trial of at least one non‑Cytokine/CAM DMARD (minimum trial 3 months) if applicableBASDAI ≥4 or ASDAS ≥2.1

For continuation, documentation of disease stability or positive clinical response (e.g., decrease in BASDAI or ASDAS) required

Atopic dermatitis

Covered when ALL of the following are met

Atopic dermatitis initial: Severe disease (e.g., BSA ≥10% or involvement of sensitive areas or equivalent severity/IGA ≥3) with functional impairment; failure, intolerance, or contraindication to topical therapies (medium/high‑potency topical corticosteroids, topical calcineurin inhibitors, topical PDE‑4 inhibitors) with minimum trial of 28 days each unless contraindicated; if applicable, trial of dupilumab for minimum 16 weeks unless contraindicated or not toleratedDupilumab trial minimum 16 weeks

For continuation, documentation of disease stability or positive response (≥20% reduction in BSA OR IGA 0–1 OR ≥50% decrease in EASI OR improvement in functional impairment) required

Crohn's Disease

Covered when ALL of the following are met

Crohn's initial: Failure, intolerance, or contraindication to conventional therapies (e.g., short‑term oral corticosteroids to induce remission; immunomodulatory agent such as methotrexate, azathioprine, or 6‑mercaptopurine with minimum trial of 12 weeks); documentation of high‑risk disease features (e.g., obstruction, abscess, stricture, phlegmon, fistulas, prior resection, extensive bowel involvement, early age of onset, growth retardation, CDAI >450, Harvey‑Bradshaw index >7)CDAI >450 or Harvey‑Bradshaw >7

For continuation, documentation of disease stability or positive clinical response (e.g., endoscopic improvement, corticosteroid taper/discontinuation, reduction in liquid stools, decreased abdominal pain, decrease in CDAI or Harvey‑Bradshaw index) required

Plaque Psoriasis

Covered when ALL of the following are met

Psoriasis initial: Ongoing disease >6 months; disease affecting at least 10% body surface area OR involving face, ears, hands, feet, or genitalia; baseline objective assessments submitted (e.g., BSA, PASI, PGA, itch numeric rating scale); history of failure, intolerance, or contraindication to phototherapy (UVB or PUVA) with minimum trial of 12 weeks AND treatment with at least one non‑Cytokine/CAM DMARD (e.g., methotrexate, cyclosporine, acitretin, azathioprine) with minimum trial of 12 weeksBSA ≥10%

For continuation, documentation of disease stability or positive clinical response (e.g., improvement in BSA, PASI, PGA, or itch score) required

Polyarticular Juvenile Idiopathic Arthritis

Covered when ALL of the following are met

Polyarticular JIA initial: Treatment with at least one non‑Cytokine/CAM DMARD (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine) that has been ineffective, unless all are contraindicated or not tolerated (minimum trial of 3 months)DMARD trial minimum 3 months

For continuation, documentation of disease stability or positive clinical response (e.g., improvement in joint pain, swelling, ADLs, reduction in disease flares) required

Psoriatic Arthritis

Covered when ALL of the following are met

PsA initial: Treatment with at least one non‑Cytokine/CAM DMARD that has been ineffective, contraindicated, or not tolerated (minimum trial of 3 months); presence of active, severe disease per provider assessment; presence of one or more of: erosive disease, elevated CRP/ESR, long‑term damage interfering with function, or major impairment of quality of life from high disease activityDMARD trial minimum 3 months

For continuation, documentation of disease stability or positive clinical response (e.g., improvement in joint pain, swelling, ADLs, reduction in flares) required

Rheumatoid Arthritis

Covered when ALL of the following are met

RA initial: Baseline disease activity assessments submitted (e.g., DAS28‑CRP/ESR, SDAI, CDAI, RAPID3, PAS II); treatment with at least one non‑Cytokine/CAM DMARD (e.g., methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, cyclosporine, azathioprine) that has been ineffective, unless all are contraindicated or not tolerated (minimum trial of 3 months)DMARD trial minimum 3 months

For continuation, documentation of disease stability or positive clinical response on disease activity scores required

Ulcerative Colitis

Covered when ALL of the following are met

Ulcerative colitis initial: Baseline assessments submitted (e.g., stool frequency, endoscopy results, presence of rectal bleeding, disease activity scoring tool); treatment with conventional therapy (e.g., systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) that has been ineffective, unless all are contraindicated or not tolerated (minimum trial of 12 weeks)Conventional therapy minimum 12 weeks

For continuation, documentation of disease stability or positive clinical response (e.g., decreased stool frequency or rectal bleeding, endoscopic improvement, or corticosteroid taper) required

If the requested medication is a non-preferred agent, the form requires documentation that the patient has had treatment with one or more preferred Cytokine and CAM medications on the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated. The form provides fields to list each preferred medication and the duration of trial, or to explain why preferred products were not tried. Providers must complete this section for non-preferred requests to allow appropriate review.

Requests that do not include the required baseline assessments, documentation of prior therapy trials, or accompanying chart notes may be considered incomplete or may be denied. The form explicitly states that chart notes are required with this request and requests the prescriber's signature, specialty, and date; absence of these materials can trigger denial or a determination of not medically necessary.

Severity Scores, Trials, and Thresholds

SALT score — alopecia areata

ThresholdSALT score >50% (Severity of Alopecia Tool)

Episode durationCurrent episode lasting >6 months required

Prior therapy requirementHistory of failure/intolerance/contraindication to high‑potency topical corticosteroids, intralesional corticosteroids, or systemic therapy (minimum trials of 6 weeks)

BASDAI — axial spondyloarthritis

BASDAI thresholdBASDAI score ≥ 4

NSAID trialTreatment with at least two different NSAIDs ineffective/contraindicated/not tolerated (minimum trial of 4 weeks each)

DMARD trialTrial of at least one non‑Cytokine/CAM DMARD if applicable (minimum 3 months)

ASDAS — axial spondyloarthritis

ASDAS thresholdASDAS score ≥ 2.1

Alternative high activity indicatorBASDAI score ≥ 4 also indicates high disease activity

Continuation requirementDocumentation of disease stability or positive clinical response (e.g., decrease in BASDAI or ASDAS) required for continuation

Crohn's CDAI — disease activity threshold

CDAI thresholdCrohn's Disease Activity Index (CDAI) > 450

High‑risk featuresDocumentation of high‑risk disease may include obstruction, abscess, stricture, fistula, resection, extensive involvement, early onset, growth retardation, or Harvey‑Bradshaw index > 7

Conventional therapy trialImmunomodulatory agent minimum trial of 12 weeks; short‑term oral corticosteroids used to induce remission as appropriate

Dupilumab trial — atopic dermatitis

Dupilumab trial durationMinimum trial of 16 weeks for dupilumab (Dupixent)

ContextUsed to determine prior failure/intolerance before authorization of cytokine/CAM antagonists for atopic dermatitis

Continuation assessmentFor continuation, documentation of disease stability or positive clinical response (e.g., ≥20% BSA reduction, IGA 0–1, ≥50% EASI reduction) required

Topical therapy trial duration — atopic dermatitis

Topical therapy minimum durationMinimum trial of 28 days each for topical corticosteroids (medium/high potency), topical calcineurin inhibitors, and topical PDE‑4 inhibitors

Applies toRequired prior trials unless contraindicated or clinically inappropriate

ExamplesTopical agents listed include clobetasol, betamethasone, halobetasol, pimecrolimus, tacrolimus, and crisaborole

Non‑Cytokine/CAM DMARD trial — minimum durations

Minimum duration (general)Minimum trial of 3 months for at least one non‑Cytokine/CAM DMARD where specified

Indications citing 3‑month DMARD trialAxial spondyloarthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis; unless all are contraindicated or not tolerated

Examples of non‑Cytokine/CAM DMARDsMethotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, cyclosporine (as listed per indication)

Phototherapy trial — psoriasis

Phototherapy minimum durationPhototherapy (UVB or PUVA) minimum trial of 12 weeks

ContextRequired prior to cytokine/CAM antagonist therapy for plaque psoriasis unless contraindicated or not tolerated

For continuationDocumentation of improvement in BSA, PASI, PGA, or itch score required

Conventional therapy trial — IBD

Conventional therapy minimum durationMinimum trial of 12 weeks for conventional therapies in inflammatory bowel disease (e.g., azathioprine, mesalamine, sulfasalazine)

ExamplesShort‑term oral corticosteroids for induction and immunomodulators (e.g., methotrexate, azathioprine, 6‑mercaptopurine) with specified minimum trials

Continuation criteriaFor continuation, documentation of disease stability or positive clinical response (e.g., endoscopic improvement, steroid taper, symptom reduction) required

Prior Authorization Submission and Required Documentation

Prior Authorization

Prior Authorization Required

Complete and fax the Cytokine and CAM Antagonists: TNF Inhibitors prior authorization request form to 866-940-7328. Allow at least 24 hours for review. For questions call 800-310-6826.

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

Step Therapy

Required Prior/Conventional Therapy Trials

Prior/conventional therapy trials must be documented before approval where specified by diagnosis. Step therapy requirements vary by indication — examples below show required trials, minimum durations, and exception allowances when therapies are contraindicated or not tolerated.

Ankylosing Spondylitis: ≥2 different NSAIDs (each minimum 4 weeks); ≥1 non-Cytokine/CAM DMARD (minimum 3 months) where indicated
Crohn's Disease: Conventional therapies such as short-term oral corticosteroids and immunomodulators (e.g., methotrexate, azathioprine, 6-MP) — immunomodulator minimum trial 12 weeks; evidence of high-risk disease may be required
Psoriasis/Atopic dermatitis: Phototherapy (UVB/PUVA) minimum 12 weeks and ≥1 non-Cytokine/CAM DMARD (minimum 12 weeks) unless contraindicated
Polyarticular JIA / Psoriatic Arthritis / RA: ≥1 non-Cytokine/CAM DMARD (minimum 3 months) unless all are contraindicated or not tolerated
Ulcerative Colitis: Conventional therapy (e.g., systemic corticosteroids, azathioprine, mesalamine, sulfasalazine) minimum 12 weeks unless contraindicated
Forms allow documentation of prior preferred agent trials on the Apple Health Preferred Drug List (AHPDL); list medications and duration or explain why not tried

Documentation Required

Required Submission Materials

Include the completed prior authorization form with required signatures and supporting clinical documentation. Missing chart notes or required fields may delay or result in denial.

Completed prior authorization form (all pages)
Prescriber signature and prescriber specialty
Prescriber NPI, telephone, fax
Patient identifiers: name, DOB, ProviderOne ID
Medication name, strength, directions, quantity/days supply
Documentation of diagnosis-specific criteria and baseline assessments (e.g., DAS28, BASDAI, ASDAS, CDAI, endoscopy results, stool frequency, CRP/ESR, BSA/Psoriasis assessments)
Documentation of prior therapy trials: drug names, durations, reasons for discontinuation (ineffective, intolerant, contraindicated)
Chart notes demonstrating disease stability or positive clinical response for continuation requests (specific measures referenced per diagnosis)

Denial Risk

Missing Clinical Documentation May Lead to Denial

Chart notes are required with every request. Absence of chart notes, prescriber signature, or prescriber specialty may result in denial or processing delays.

Chart notes documenting baseline assessments and response to therapy
Prescriber signature
Prescriber specialty
Date