CurrentColorado Rocky Mountain Health PlansPolicy N/A

Pharmacy Prior Authorization Request Form for Injectable Biologic Therapy

A payer pharmacy prior authorization (PA) request form used to request coverage for injectable biologic immunomodulators for specific diagnoses (NOMID, Rheumatoid Arthritis, DIRA). The form collects beneficiary, prescriber, drug, and diagnosis-specific checklist items confirming prior treatments, testing, and contraindications required for PA processing.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPharmacy Prior Authorization Request Form for Injectable Biologic Therapy

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the pharmacy prior approval request form providing beneficiary, prescriber, drug, length of therapy, and diagnosis-specific checklist items; prescriber signature is mandatory.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an administrative prior authorization form used to collect information for injectable biologic immunomodulators.

3Diagnoses with specific checklists on form

1Mandatory prescriber signature

Policy Overview

This is a payer pharmacy prior authorization request form to request coverage for injectable biologic immunomodulators for three specific diagnoses: Neonatal-Onset Multisystem Inflammatory Disease (NOMID), Rheumatoid Arthritis (RA), and Deficiency of Interleukin-1 Receptor Antagonist (DIRA).

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The form collects standard administrative information: beneficiary details (name, ID, DOB, gender), prescriber details (provider NPI, requester contact), and drug details (drug name, strength, quantity, length of therapy selections).

For each diagnosis the form contains a checklist of required clinical confirmations, including: confirmation of the specified diagnosis; confirmation the beneficiary is not on another injectable biologic immunomodulator; documentation that the beneficiary has been considered and screened for latent tuberculosis infection; and documentation of testing for Hepatitis B surface antigen and core antibody.

The Rheumatoid Arthritis checklist additionally requires documentation of prior therapeutic failure or inadequate response to methotrexate or at least one disease-modifying antirheumatic drug (DMARD), information on contraindications or intolerances to methotrexate/DMARDs or evidence of severe/rapidly progressing disease, and trial/failure of or clinical reason precluding use of Enbrel or Humira.

The form requires the prescriber’s signature (mandatory) certifying the accuracy and completeness of the information for PA processing.

Coverage Criteria by Indication

Request for Neonatal Onset Multisystem Inflammatory Disease (NOMID)

Covered when ALL of the following are met:

ALL of the following

Beneficiary has a diagnosis of neonatal-onset multisystem inflammatory disease (NOMID)
Beneficiary is not on another injectable biologic immunomodulator
Beneficiary has been considered and screened for the presence of latent tuberculosis infection
Beneficiary has been tested with Hep B SAG and Core Ab

Request for Rheumatoid Arthritis

Covered when ALL of the following are met:

ALL of the following

Beneficiary has a diagnosis of Rheumatoid Arthritis
Beneficiary is not on another injectable biologic immunomodulator
Beneficiary has been considered and screened for the presence of latent tuberculosis infection
Beneficiary has been tested with Hep B SAG and Core Ab
Beneficiary has experienced therapeutic failure or inadequate response with methotrexate or at least one disease-modifying antirheumatic drug (e.g. leflunomide, hydroxychloroquine, minocycline, sulfasalazine)
OR

Request for Deficiency of Interleukin-1 Receptor Antagonist (DIRA)

Covered when ALL of the following are met:

ALL of the following

Beneficiary has a diagnosis of Deficiency of Interleukin-1 Receptor Antagonist (DIRA)
Beneficiary is not on another injectable biologic immunomodulator
Beneficiary has been considered and screened for the presence of latent tuberculosis infection
Beneficiary has been tested with Hep B SAG and Core Ab

Required Provider Actions and Documentation

Prior Authorization

Prescriber must submit prior authorization request

Prescriber must complete and sign the pharmacy prior approval request form providing beneficiary, prescriber, drug, length of therapy, and diagnosis-specific checklist items; prescriber signature is mandatory.

Documentation Required

Documentation of prior therapy and testing required

For rheumatoid arthritis and other covered diagnoses, document prior therapeutic failure or inadequate response with methotrexate or at least one disease‑modifying antirheumatic drug; record trials and failures of Enbrel or Humira or provide clinical reasons they cannot be used; confirm screening for latent tuberculosis infection; and confirm Hepatitis B surface antigen and core antibody testing.

Therapeutic failure or inadequate response with methotrexate or at least one DMARD (e.g., leflunomide, hydroxychloroquine, minocycline, sulfasalazine)
Trial and failure of Enbrel or Humira, or documented clinical reason beneficiary cannot try Enbrel or Humira
Screening for latent tuberculosis infection
Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab) testing

Form Metadata & Scope

Key Values

SubjectPharmacy Prior Authorization Request Form for Injectable Biologic Therapy

StatusCURRENT

Diagnoses with specific checklists on form3

Mandatory prescriber signature1

Scope summaryA payer pharmacy prior authorization (PA) request form used to request coverage for injectable biologic immunomodulators for specific diagnoses (NOMID, Rheumatoid Arthritis, DIRA). The form collects beneficiary, prescriber, drug, and diagnosis-specific checklist items confirming prior treatments, testing, and contraindications required for PA processing.

Revision History

revision_historyLatest

No revision history entries were provided in the brief; policy status is CURRENT. Effective date, last review date, and next review date are not specified.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPharmacy Prior Authorization Request Form for Injectable Biologic Therapy

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

SourceLink

On This Page

Beneficiary is unable to receive methotrexate or disease-modifying antirheumatic drug due to contraindications or intolerabilities

Beneficiary has clinical evidence of severe or rapidly progressing disease

Beneficiary has had a trial and failure of Enbrel or Humira or there is a clinical reason beneficiary cannot try Enbrel or Humira