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Patient
First name
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Last name
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Date of birth
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MRN
Insurance
Payer
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BCBS Illinois
UnitedHealthcare
Aetna
Cigna
Humana
UHC Medicare Advantage
Aetna Medicare Advantage
IL Medicaid (Meridian)
IL Medicaid (Molina)
Member ID
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Group #
Diagnosis & biologic
Primary ICD-10
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L40.0 — Plaque psoriasis
L40.50 — Psoriatic arthropathy
L20.9 — Atopic dermatitis
L20.81 — Atopic neurodermatitis
L73.2 — Hidradenitis suppurativa
L63.9 — Alopecia areata
L63.1 — Alopecia totalis
L63.2 — Alopecia universalis
L50.0 — Chronic urticaria
Biologic requested
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Clinical criteria
PASI score
BSA (%)
Conventional therapy failures
Methotrexate
Cyclosporine
Acitretin
Phototherapy
Apremilast
Clinical notes
Urgency
Standard (2–3 business days)
Urgent (same day / 24 hr)
Expedited appeal
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