CurrentColorado Rocky Mountain Health PlansPolicy N/A

Immunomodulators: Stelara Infusion (North Carolina) Prior Authorization Form - Community Planopen_in_new

A prescriber-completed prior authorization request form for community plan members in North Carolina seeking coverage for Stelara infusion (ustekinumab) for adult Crohn's disease or ulcerative colitis, capturing beneficiary, prescriber, drug details, therapy length, and Yes/No clinical attestation items required for approval.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyImmunomodulators: Stelara Infusion (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form, provide beneficiary and prescriber information, answer required clinical Yes/No attestation items, select length of therapy, and date the signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

2Indications listed on form

5Required attestation items per indication

Coverage Summary

Coverage stance: covered_with_criteria. Scope: A prescriber-completed prior authorization request form for community plan members in North Carolina seeking coverage for Stelara infusion (ustekinumab) for adult Crohn's disease or ulcerative colitis, capturing beneficiary, prescriber, drug details, therapy length, and Yes/No clinical attestation items required for approval. Subject: Stelara (ustekinumab) infusion prior authorization form for Crohn's disease and ulcerative colitis. Status: CURRENT.

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General Submission Requirements

Form must be completed and signed by prescriber; required data elements and attestation questions must be provided.

ALL of the following

Beneficiary identifying information provided (last name, first name, beneficiary ID, DOB, gender)
Prescribing provider NPI provided
Requester contact name and phone provided
Drug name, strength, quantity per 30 days, and requested length of therapy selected
Prescriber signature and date (Prescriber signature mandatory)

Prior Authorization

Complete and sign prior authorization form

Prescriber must complete and sign the prior authorization form. The form collects beneficiary identifying information, prescriber NPI and requester contact, drug details and requested length of therapy, and requires the prescriber’s signature and date. Prescriber signature is mandatory.

Mandatory prescriber signature (Signature of Prescriber; Prescriber Signature Mandatory)
Required form fields: beneficiary last name, first name, beneficiary ID, date of birth, gender
Required form fields: prescribing provider NPI, requester contact name and phone
Required drug fields: drug name, strength, quantity per 30 days, and selected length of therapy (up to 30, 60, 90, 120, 180, 365 days or other)

Initial Therapy Criteria — Crohn's Disease (Adult)

Criteria for Stelara infusion request - Crohn's Disease (Adult)

Covered when ALL of the following are affirmed:

ALL of the following

Beneficiary has a diagnosis of moderate to severe Crohn's Disease
Form asks Yes/No
Beneficiary is not on another injectable biologic immunomodulator
Form asks Yes/No
Beneficiary has been considered and screened for latent tuberculosis infection
Form asks Yes/No
Beneficiary has been tested with Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab)
Form asks Yes/No
ONE of
- Beneficiary had a trial and failure of Humira (adalimumab)
- There is a clinical reason the beneficiary cannot try Humira

Documentation Required

Document disease diagnosis and prior biologic trial (Crohn's disease)

Provider must attest to the beneficiary’s diagnosis and prior biologic exposure and screening. For Crohn’s disease requests the form requires attestation that the beneficiary has moderate to severe Crohn’s disease, has been considered and screened for latent tuberculosis, has Hepatitis B testing (Hep B SAG and Core Ab), is not on another injectable biologic immunomodulator, and has had a trial and failure of Humira (adalimumab) or there is a clinical reason Humira cannot be tried.

Attest diagnosis: moderate to severe Crohn's disease
TB screening: beneficiary considered and screened for latent tuberculosis infection
Hepatitis B testing: Hep B SAG and Hep B core antibody (Core Ab)
Attest not on another injectable biologic immunomodulator
Document prior trial and failure of Humira (adalimumab) or provide clinical justification why Humira cannot be tried

Initial Therapy Criteria — Ulcerative Colitis (Adult)

Criteria for Stelara infusion request - Ulcerative Colitis (Adult)

Covered when ALL of the following are affirmed:

ALL of the following

Beneficiary has a diagnosis of ulcerative colitis
Form asks Yes/No
Beneficiary is not on another injectable biologic immunomodulator
Form asks Yes/No
Beneficiary has been considered and screened for latent tuberculosis
Form asks Yes/No
Beneficiary has been tested with Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab)
Form asks Yes/No
ONE of
- Beneficiary had a trial and failure of Humira (adalimumab)
- There is a clinical reason the beneficiary cannot try Humira

Documentation Required

Document disease diagnosis and prior biologic trial (Ulcerative colitis)

For ulcerative colitis requests the provider must similarly attest that the beneficiary has ulcerative colitis, has been considered and screened for latent tuberculosis, has Hepatitis B testing (Hep B SAG and Core Ab), is not on another injectable biologic immunomodulator, and has had a trial and failure of Humira (adalimumab) or there is a clinical reason Humira cannot be tried.

Attest diagnosis: ulcerative colitis
TB screening: beneficiary considered and screened for latent tuberculosis
Hepatitis B testing: Hep B SAG and Hep B core antibody (Core Ab)
Attest not on another injectable biologic immunomodulator
Document prior trial and failure of Humira (adalimumab) or provide clinical justification why Humira cannot be tried

Background

Background: This is a plan-specific prior authorization form used to request coverage for Stelara (ustekinumab) infusion for adults with Crohn's disease or ulcerative colitis. The form collects patient (beneficiary name, ID, DOB, gender), prescriber (including NPI and requester contact), and drug information (drug name, strength, quantity per 30 days, and selectable length of therapy). It also requires mandatory prescriber signature and date and includes clinical attestation items capturing screening for latent tuberculosis and Hepatitis B, plus documentation of prior biologic exposure or trial and failure of Humira (adalimumab).

Key background

PayerColorado Rocky Mountain Health Plans

Policy titleImmunomodulators: Stelara Infusion (North Carolina) Prior Authorization Form - Community Plan

Effective Date

StatusCURRENT

Indications listed on form2 (Crohn's disease; Ulcerative colitis)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyImmunomodulators: Stelara Infusion (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Immunomodulators: Stelara Infusion (North Carolina) Prior Authorization Form - Community Planopen_in_new

Coverage Summary

General Submission Requirements

Initial Therapy Criteria — Crohn's Disease (Adult)

Initial Therapy Criteria — Ulcerative Colitis (Adult)

Applicable Codes

Background

Definitions

Revision History