CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Request Form for Injectable Biologic Therapies (multiple indications)

This is a beneficiary/prescriber prior authorization request form used by Colorado Rocky Mountain Health Plans to document clinical criteria for coverage of injectable biologic immunomodulator therapies across multiple indications (ankylosing spondylitis, Crohn's disease adult/pediatric, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis adult/pediatric). It captures diagnosis confirmation, prior treatment trials/failures, screening for latent TB and hepatitis B, age and disease severity criteria, and medication-specific trial/failure requirements.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Request Form for Injectable Biologic Therapies (multiple indications)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete beneficiary and prescriber sections, answer all indication-specific checklist items, and sign the form certifying accuracy; unsigned forms are not compliant.

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

8Indications covered by form

3Common required screenings

1Mandatory prescriber signature

Coverage Summary

This is a prior authorization request form for injectable biologic immunomodulator therapies used across multiple indications. It covers eight indications: ankylosing spondylitis, Crohn's disease (adult and pediatric), plaque psoriasis (adult), psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis (adult and pediatric). The form documents required items for authorization including diagnosis confirmation, prior medication trials/failures or documented clinical reasons why specified agents cannot be used, and common screening checks for latent tuberculosis and hepatitis B (Hep B SAG and Core Ab). This document functions as an authorization request form to verify clinical prerequisites before coverage is approved for these injectable biologic agents.

Quick Facts and Key Thresholds

Indications covered by form8

Common required screeningsTB, Hep B (SAG and Core Ab), and prior biologic status

Mandatory prescriber signature1 (prescriber signature required and certified)

Plaque Psoriasis BSA involvement>= 3%

Authorization Criteria (by indication)

General Authorization Questions (applies to all indication-specific sections)

Form fields that must be affirmed for authorization:

ALL of the following

Prescriber completes beneficiary and prescriber information and signs the form
Prescriber signature mandatory
Beneficiary has the specific diagnosis for the requested indication (see indication-specific sections)
Beneficiary is not on another injectable biologic immunomodulator
Checkboxed 'Is the beneficiary not on another injectable biologic immunomodulator?' required
Beneficiary has been considered and screened for the presence of latent tuberculosis infection
Checkbox required (not required for Otezla per psoriasis section)
Beneficiary has been tested with Hep B SAG and Core Ab
Checkbox required

Provider Requirements and Documentation

Prior Authorization

Complete and sign prior authorization form

Prescriber completes beneficiary and prescriber sections, answers all indication-specific checklist items, and provides mandatory prescriber signature certifying accuracy; unsigned forms are not compliant.

Unsigned forms are not compliant

Documentation Required

Document prior treatment trials and contraindications

Provider must document trials and failures of specified medications or provide clinical reasons why those agents cannot be used.

Cosentyx
Enbrel
Humira
methotrexate/DMARDs
phototherapy
systemic psoriasis agents

Documentation Required

TB and Hepatitis B screening required

Provider must confirm latent TB screening and Hep B (SAG and Core Ab) testing; note: latent TB screening not required when requesting Otezla per plaque psoriasis and psoriatic arthritis sections.

latent TB screening not required for Otezla per plaque psoriasis and psoriatic arthritis sections

Documentation Required

Age verification for indication-specific agents

Provider must document beneficiary age for indications with age requirements.

>=18 years for adult indications; Simponi Aria allows >=2 years for psoriatic arthritis when applicable

Background

This template is an authorization request checklist designed to capture the clinical prerequisites needed to approve various injectable biologic immunomodulators across rheumatology, dermatology and gastroenterology indications. It requires the prescriber to complete beneficiary and prescriber information and provide a mandatory signature certifying accuracy.

The form’s purpose includes screening for latent tuberculosis infection (checkboxed for most indications, with a specific note that latent TB screening is not required when Otezla is requested in certain psoriasis/psoriatic arthritis sections) and documenting testing for Hep B (SAG and Core Ab). It also captures prior medication trials and failures (for example, trials of Humira for IBD, Cosentyx/Enbrel/Humira for several indications, methotrexate or other DMARDs for rheumatoid arthritis, and phototherapy plus systemic psoriasis agents for plaque psoriasis) or requires documentation of clinical reasons why those agents cannot be used.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Request Form for Injectable Biologic Therapies (multiple indications)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete beneficiary and prescriber sections, answer all indication-specific checklist items, and sign the form certifying accuracy; unsigned forms are not compliant.

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