CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Form for Biologic/Drug Therapy for Rheumatoid Arthritis

A prescriber-completed prior authorization request form to document beneficiary, prescriber, and drug information and to record clinical criteria for use of a biologic/immunomodulator for rheumatoid arthritis (RA), including prior therapy, screening for latent TB and hepatitis B, contraindications to methotrexate/DMARDs, and trials of specific agents (Enbrel, Humira).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Form for Biologic/Drug Therapy for Rheumatoid Arthritis

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete the prior authorization form, answer all RA screening questions (TB, Hep B), document prior DMARD/biologic therapy or contraindications, and sign/date the form.

POLICY UPDATE CHANGES

No material clinical/coverage changes

7Required Clinical Questions on Form

1Mandatory Prescriber Signature

Coverage Summary

This is a prescriber-completed prior authorization request form to document beneficiary, prescriber, and drug information and to record clinical criteria for use of a biologic/injectable immunomodulator for rheumatoid arthritis (RA), including prior therapy, screening for latent TB and hepatitis B, contraindications to methotrexate/DMARDs, and trials of specific agents (Enbrel, Humira). Request may be approved when ALL of the listed criteria are documented: diagnosis of RA; not currently on another injectable biologic immunomodulator; considered and screened for latent tuberculosis; tested with HBsAg and Hep B Core Ab; documentation of therapeutic failure or intolerance/contraindication to methotrexate or at least one DMARD; clinical evidence of severe/rapidly progressing disease; and prior trial/failure of Enbrel or Humira or a documented clinical reason they cannot be tried.

Required Provider Actions

Prior Authorization

Submit completed prior authorization form

Prescriber must complete the prior authorization form with beneficiary, prescriber and drug fields; answer all RA clinical screening questions including latent TB screening and Hepatitis B (HBsAg and Core Ab) testing; indicate prior DMARD/biologic therapy status; and provide prescriber signature and date (signature is mandatory).

Complete beneficiary identifying information (name, ID, DOB, gender).
Provide prescriber identification and contact (including NPI).
Enter drug name, strength, quantity, and length of therapy.
Answer RA screening questions: diagnosis of RA, current use of another injectable biologic, latent TB screening, Hep B testing.
Document prior DMARD/biologic therapy status.
Sign and date the form (prescriber signature mandatory).

Documentation Required

Document prior therapy and contraindications

Document either therapeutic failure or inadequate response to methotrexate or at least one other DMARD, or a documented contraindication/intolerance to methotrexate/DMARDs; and document a trial and failure of Enbrel (etanercept) or Humira (adalimumab) or provide a clinical reason the beneficiary cannot try Enbrel or Humira.

Check/document therapeutic failure or inadequate response with methotrexate or another DMARD (examples: leflunomide, hydroxychloroquine, minocycline, sulfasalazine).
Or document contraindication or intolerance to methotrexate/DMARDs.
Document trial and failure of Enbrel or Humira, or document clinical reason they cannot be tried.

Background & Definitions

This authorization form is used to gather necessary clinical information to determine medical necessity for initiating or authorizing a biologic or injectable immunomodulator for rheumatoid arthritis. The form records screening for infectious risks — specifically asking whether the beneficiary has been considered and screened for the presence of latent tuberculosis and whether the beneficiary has been tested with Hep B SAg and Core Ab. The form also requires documentation of prior treatment trials or contraindications to conventional therapy, including whether the beneficiary experienced therapeutic failure or inadequate response with methotrexate or at least one DMARD, or is unable to receive methotrexate/DMARD due to documented contraindication or intolerance, and it requires the prescriber's signature (mandatory).

DMARD: Disease-modifying antirheumatic drug (examples listed on form: leflunomide, hydroxychloroquine, minocycline, sulfasalazine, methotrexate).