Public reference
Payer Policy Library for specialty drug appeals
Coverage criteria, documentation checklists, appeal windows and submission channels for 6 major commercial payers, sourced from published medical benefit drug policies and clinical policy bulletins. Clinics using Akeso AI also upload their own bulletins, which stay private and take precedence in their appeal dossiers.
Coverage criteria by payer
UnitedHealthcare
UHC Commercial Medical Benefit Drug Policy 2024D0044AA
180 days from the date of denial
Provider Portal upload + fax 866-747-9111
- Documented 12-week trial of a topical corticosteroid or vitamin D analog
- Trial and failure of one preferred TNF inhibitor (adalimumab biosimilar)
- Contraindication statement required to bypass preferred agents
- Chart notes covering the last 6 months of therapy
- Objective severity scoring (PASI / BSA / EASI) at two time points
- Prior medication list with start/stop dates and reason for discontinuation
- Signed letter of medical necessity from the prescriber
Appeals fax 866-747-9111 · Provider portal provider.uhcprovider.com · Appeals address UnitedHealthcare Appeals, P.O. Box 30432, Salt Lake City, UT 84130
Aetna
Aetna Clinical Policy Bulletin 0872 — Dupilumab
180 days from the date of denial
Availity attachment + certified mail
- Trial of medium-to-high potency topical therapy for at least 4 weeks
- Trial of one systemic agent (cyclosporine or methotrexate) unless contraindicated
- EASI or IGA score documentation
- Body surface area involvement and affected sites
- Documented intolerance details including adverse events
- Confirmation of age-appropriate indication
Appeals fax 859-455-8650 · Provider portal availity.com · Appeals address Aetna Provider Resolution Team, P.O. Box 14020, Lexington, KY 40512
Cigna
Cigna Coverage Policy IP0021 — Immunomodulators
365 days from the date of denial
Cigna for Health Care Professionals portal
- Preferred biosimilar must be trialed for 12 weeks before reference product
- Non-medical switch appeals require stability documentation on current agent
- Evidence of sustained disease control on the current agent
- Immunogenicity or antibody testing if available
- Prescriber attestation on switch risk
Appeals fax 866-873-8279 · Provider portal cignaforhcp.cigna.com · Appeals address Cigna Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
Blue Cross Blue Shield
BCBS Medical Policy 5.01.550 — Disease-Modifying Therapies
180 days from the date of denial
Secure provider portal, peer-to-peer within 10 days
- Documented failure of at least one platform therapy for MS
- Baseline MRI within 12 months required
- MRI reports demonstrating new or enlarging lesions
- EDSS score progression
- Relapse history with dates and treatment
Appeals fax 877-361-7656 · Provider portal provider.bcbs.com · Appeals address BCBS Clinical Appeals, P.O. Box 2291, Durham, NC 27702
Humana
Humana Pharmacy Coverage Policy — Vedolizumab (Entyvio)
65 days from the date of denial
Humana provider portal, expedited fax for urgent
- Trial of corticosteroids and one immunomodulator for IBD indications
- Vedolizumab requires documented anti-TNF failure or intolerance
- Endoscopy or colonoscopy report within 12 months
- Calprotectin or CRP labs demonstrating active inflammation
- Mayo or Harvey-Bradshaw index score
Appeals fax 800-949-2961 · Provider portal humana.com/provider · Appeals address Humana Grievances & Appeals, P.O. Box 14165, Lexington, KY 40512
Anthem
Anthem Clinical UM Guideline CG-DRUG-142 — Asthma Biologics
180 days from the date of denial
Anthem provider portal + clinical review request
- High-dose ICS/LABA for 3 months prior to biologic initiation
- Eosinophil count or FeNO threshold documentation
- Spirometry (FEV1) pre and post bronchodilator
- Exacerbation history with steroid bursts and ED visits
- ACT score documentation
Appeals fax 888-458-1406 · Provider portal providers.anthem.com · Appeals address Anthem Central Appeals Processing, P.O. Box 61599, Virginia Beach, VA 23466
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