UnitedHealthcare TNF Inhibitors Prior Auth Coverage | OpenPayer

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UnitedHealthcare TNF Inhibitors Prior Auth Coverage | OpenPayer

Scales, Scores, and Definition Thresholds

BASDAI — high disease activity

BASDAI high disease activity thresholdBASDAI score of at least 4

ContextUsed to identify high disease activity for ankylosing spondylitis/non-radiographic axial spondyloarthritis

Source questionDocument asks: 'Does patient have high disease activity as indicated by one of the following? - Bath Ankylosing Disease Activity Index (BASDAI) score of at least 4'

ASDAS — high disease activity

ASDAS high disease activity thresholdASDAS score of at least 2.1

ContextUsed to identify high disease activity for ankylosing spondylitis/non-radiographic axial spondyloarthritis

Source questionDocument asks: 'Does patient have high disease activity as indicated by one of the following? - Ankylosing Spondylitis Disease Activity Score (ASDAS) score of at least 2.1'

SALT score — severe Alopecia areata

SALT score threshold for severe alopecia areataSALT score >50% (≥50% scalp hair loss)

Episode duration requirementCurrent episode lasting more than 6 months is required in criteria

Minimum prior therapy trialsHistory of failure/contraindication/intolerance to topical, intralesional, or systemic therapies with minimum trials of 6 weeks each

Dupilumab trial — minimum duration

Dupilumab trial durationMinimum trial of 16 weeks

ApplicabilityRequired for Atopic Dermatitis criteria prior to TNF inhibitor consideration when dupilumab is not appropriate or ineffective

DocumentationForm asks whether treatment with dupilumab has been ineffective, contraindicated, or not tolerated with minimum 16-week trial

High disease activity (AS/nr-axSpA)

DefinitionHigh disease activity defined as BASDAI ≥4 OR ASDAS ≥2.1

IndicationApplies to Ankylosing Spondylitis (AS) and Non-radiographic axial spondyloarthritis (nr-axSpA)

Use in criteriaRequired element on form to establish initiation eligibility and for continuation assessment (with documentation of response)

Severe Alopecia areata — definition

DefinitionSevere alopecia areata defined as current episode >6 months AND SALT score >50%

Required prior therapiesForm requires documentation of failure/contraindication/intolerance to topical intralesional and systemic therapies (minimum 6-week trials)

Continuation requirementFor continuation of therapy, documentation of positive clinical response must be submitted

What Providers Must Submit / Actions Required

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests. Allow at least 24 hours for review. Complete and fax the entire prior authorization request form to the number provided; incomplete submissions may be delayed or denied.

Fax complete prior authorization form to 866-940-7328
Allow at least 24 hours for review
Call 800-310-6826 with questions

Step Therapy

Preferred Product Trial Required

If the requested medication is non-preferred, the provider must document that the patient had a trial and failure, intolerance, or contraindication to one or more preferred Cytokine and CAM medications listed on the Apple Health Preferred Drug List (AHPDL). For each preferred product tried, include the medication name and duration of trial. If a preferred product was not tried, provide a clear explanation why.

List each preferred medication trial and duration when request is for a non-preferred product
If no preferred product trial, provide reason why preferred products were not tried (e.g., contraindication, intolerance)

Documentation Required

Required Submission Elements

Complete the entire prior authorization form. Ensure all required fields and diagnosis-specific questions are answered, including patient demographics, prescriber information (including specialty and signature), medication name/strength/directions/qty, indication and associated question set for the diagnosis, and current patient weight with date.

Provide patient demographics and date of birth
Include prescriber name, NPI, specialty, telephone, fax, and signature
Specify medication name, strength, directions for use, quantity and days' supply
Indicate whether request is for continuation of therapy and provide documentation of disease stability or positive response if continuation
Select prescriber specialty or consulting specialty (e.g., Allergist, Dermatologist, Gastroenterologist, Immunologist, Rheumatologist)
Answer diagnosis-specific questions (e.g., disease severity and functional impairment for atopic dermatitis; specific question sets for listed diagnoses)

Denial Risk

Chart Notes Required — Missing Documentation Risk

Chart notes are required with this request. Failure to include supporting chart documentation (e.g., clinical notes demonstrating prior therapy trials, response, intolerance, contraindications, weight) may delay review or result in denial.

Attach chart notes demonstrating prior medication trials, clinical response or stability, and other supporting clinical information
Omission of chart notes may delay decision or cause denial