Dermatology prior authorization at Regence
PA workflow, documentation criteria, and peer-to-peer prep — for prescribers and PA staff
Regence dermatology PA at a glance
Regence reviews dermatology PA submissions against its medical policy library, with rules drawn primarily from AAD (American Academy of Dermatology) + NPF (National Psoriasis Foundation) for psoriasis. Regence-specific context: BCBS licensee operating in Oregon, Washington (Clark/Cowlitz counties), Idaho, and Utah (~3.1M members). Subsidiary of Cambia Health Solutions. Prime Therapeutics PBM. Each state's DOI handles complaints for policies issued in that state.
Documentation packet — what to send
- Diagnosis with ICD-10
- Severity score (PASI, BSA, IGA for psoriasis; EASI, IGA for AD)
- DLQI quality-of-life score
- Prior therapies tried: topicals, phototherapy, oral systemics
- Reason for discontinuation of each prior therapy
Common denial patterns to pre-empt
Patterns observed in dermatology across payers, and where Regence's book of business overlaps:
- Psoriasis: PASI / BSA / IGA severity thresholds not met (typically PASI ≥10 or BSA ≥10%)
- Atopic dermatitis: severity score (EASI ≥21) not documented
- Step therapy through topicals / phototherapy first
- Quality-of-life impact (DLQI ≥10) not documented
- Special sites (face, scalp, hands) not flagged
- Step therapy via Prime Therapeutics
- Specialty drug PA
Appeal angles when Regence denies
- AAD-NPF guideline citation for psoriasis
- AAD Atopic Dermatitis guideline citation
- DLQI severity argument
- Special-site involvement (face, hands, genitals) supporting expedited biologic
Peer-to-peer prep
- Have photos / clinical findings ready
- Quote the AAD-NPF guideline by year and recommendation grade
- Document failed phototherapy explicitly (NB-UVB, sessions, response)
- For DLQI: state the score AND the specific functional impacts patient reports
Drug-specific PA criteria at Regence
Deep dives on each drug's PA criteria at Regence:
Frequently asked questions
What documentation does Regence need for dermatology prior authorizations?
Regence's PA packet for dermatology typically includes: Diagnosis with ICD-10; Severity score (PASI, BSA, IGA for psoriasis; EASI, IGA for AD); DLQI quality-of-life score; Prior therapies tried: topicals, phototherapy, oral systemics. AAD (American Academy of Dermatology) + NPF (National Psoriasis Foundation) for psoriasis citations strengthen the submission.
What's the turnaround at Regence?
Regence standard decision: 30 days. Expedited (urgent care): 72 hours per 45 CFR §147.136. Internal appeal window if denied: 180 days.
Which dermatology drugs does Regence most often PA-restrict?
Top targets in dermatology: adalimumab, ustekinumab, secukinumab, guselkumab, risankizumab. Each follows the per-drug step therapy + documentation requirements published in Regence's medical policy library.
How do I prep a peer-to-peer with Regence in dermatology?
Have photos / clinical findings ready Quote the AAD-NPF guideline by year and recommendation grade Have the policy URL and the patient's chart open before the call.
Generate a Dermatology PA packet
Open ApprovalHelp — generate a dermatology PA packet tailored to Regence's criteria, with prescriber attestation and supporting citations pre-filled.
Get started →Contact: hello@approvalhelp.com