CurrentUnitedHealthcarePolicy N/A

Pharmacy Prior Authorization Form — Injectable Biologic Immunomodulators for Plaque Psoriasis, Psoriatic Arthritis, and Behcet's Disease (oral ulcers)

A pharmacy prior authorization request form used by UnitedHealthcare to document clinical criteria for approving injectable biologic immunomodulator therapy for adult beneficiaries with chronic plaque psoriasis, psoriatic arthritis, or oral ulcers associated with Behcet's disease. It affects prescribers requesting prior authorization through the payer's pharmacy PA process.

Policy Summary

PayerUnitedHealthcare

PolicyPharmacy Prior Authorization Form — Injectable Biologic Immunomodulators (psoriasis, psoriatic arthritis, Behcet's)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and sign the Pharmacy Prior Approval Request form and provide required documentation including diagnosis, age, prior therapy trials, BSA (for psoriasis), and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3clinical conditions covered

18minimum adult age

BSA >= 3%psoriasis BSA threshold

3 named biologicsnamed biologics required trial

Prescriber signature requiredmandatory signature

Coverage Criteria for Biologic Therapy

Initial Therapy — Plaque Psoriasis

Covered when ALL of the following are met for plaque psoriasis (adult):

ALL of the following

Documented definitive diagnosis of moderate-to-severe chronic plaque psoriasis.
Beneficiary is 18 years of age or older.
Beneficiary is not currently receiving another injectable biologic immunomodulator.
Body surface area (BSA) involvement of at least 3%.
Involvement of palms, soles, head and neck, or genitalia causing disruption in normal daily activities and/or employment.

Policy Summary

PayerUnitedHealthcare

PolicyPharmacy Prior Authorization Form — Injectable Biologic Immunomodulators (psoriasis, psoriatic arthritis, Behcet's)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Initial Therapy — Psoriatic Arthritis

Covered when ALL of the following are met for psoriatic arthritis:

ALL of the following

Documented definitive diagnosis of psoriatic arthritis.
Beneficiary is 18 years of age or older. (Note: Simponi Aria may be authorized for beneficiaries 2 years or older per product labeling where applicable.)
Beneficiary is not currently receiving another injectable biologic immunomodulator.
Documented inadequate response to, or inability to take, methotrexate.
Trial and failure of Cosentyx, Enbrel, or Humira, or a documented clinical reason the beneficiary cannot try Cosentyx, Enbrel, or Humira.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for injectable biologic immunomodulators. The prescriber must complete and sign the Pharmacy Prior Approval form; unsigned forms will delay or trigger denial.

Prior authorization required for injectable biologic immunomodulators
Prescriber must complete and sign the Pharmacy Prior Approval Request (prescriber signature mandatory)
Pharmacy PA Call Center: 1-855-258-1593

Documentation Required

Required Documentation on PA Form

Provider must supply complete beneficiary, prescriber, and drug information on the PA form. Incomplete or missing documentation may result in delay or denial of the request.

Beneficiary demographics: name, ID number, date of birth, gender
Prescriber information: prescribing provider NPI, requester contact name and phone/extension
Drug details: drug name, strength, quantity per 30 days, length of therapy
Clinical information: definitive diagnosis, age, body surface area (when applicable), prior therapies/trials and reasons for contraindication or intolerance
Specific condition sections: completed disease-specific checklist (e.g., plaque psoriasis, psoriatic arthritis, Behcet's disease)
Prescriber attestation and signature (signature mandatory) and date

Denial Risk

Triggers for Denial or Delay

Requests may be denied or delayed if the PA form is incomplete, unsigned, lacks a documented diagnosis, does not meet age or prior-treatment criteria, or indicates the beneficiary is currently on another injectable biologic immunomodulator when contraindicated.

Incomplete or unsigned PA form — includes missing prescriber signature
Missing or unclear diagnosis documentation (no definitive diagnosis of the requested indication)
Failure to meet age requirements for the indication (e.g., must be ≥18 years unless specified otherwise)
No documentation of prior medication trials, failures, or contraindications when required (e.g., phototherapy and one systemic for plaque psoriasis; methotrexate for psoriatic arthritis)
Documentation shows beneficiary is currently on another injectable biologic immunomodulator when policy requires not being on one
Lack of required clinical measures (e.g., BSA for plaque psoriasis) or absence of disease-specific checklist responses

Background

This Pharmacy Prior Approval request form is limited in scope to requests for injectable biologic immunomodulator therapy for three clinical indications: chronic plaque psoriasis (adult), psoriatic arthritis, and oral ulcers associated with Behcet's disease. For each indication the form captures a confirmed diagnosis, beneficiary age, current biologic status, and the indication-specific prior treatment or trial requirements that determine eligibility for initial coverage.

Providers must complete the indication-specific checklist on the form: for plaque psoriasis the form documents disease extent (including BSA ≥ 3% and involvement of special anatomic sites) and prior phototherapy/systemic therapy trials; for psoriatic arthritis it documents methotrexate response/intolerance and prior biologic trials; and for Behcet's disease it documents diagnosis, age, and non-use of another injectable biologic.

Definitions and Diagnostic Thresholds

inv-12: Moderate-to-severe chronic plaque psoriasis — Diagnosis plus BSA >= 3% or involvement of certain sites

Required diagnosisDocumented definitive diagnosis of moderate-to-severe chronic plaque psoriasis

Age requirementBeneficiary must be 18 years of age or older

BSA or special-site involvementBSA involvement >= 3% or involvement of palms, soles, head/neck, or genitalia causing disruption in daily activities or employment

Prior therapiesFailed or unable to tolerate phototherapy and one systemic agent (acitretin/Soriatane, methotrexate, or cyclosporine) or has contraindications

Prior biologic trialTrial and failure of Cosentyx, Enbrel, or Humira or documented clinical reason these cannot be tried

inv-13: Psoriatic arthritis — Documented diagnosis in an adult with inadequate response or intolerance to conventional therapy

Required diagnosisDocumented definitive diagnosis of psoriatic arthritis

Age requirementBeneficiary must be 18 years of age or older (or 2 years or older for Simponi Aria as noted)

Methotrexate requirementDocumented inadequate response or inability to take methotrexate

Prior biologic trialTrial and failure of Cosentyx, Enbrel, or Humira or documented clinical reason these cannot be tried

inv-14: Behcet's disease (oral ulcers) — Documented diagnosis in an adult requesting biologic therapy for oral ulcers associated with Behcet's disease

Required diagnosisDocumented diagnosis of Behcet's disease with oral ulcers

Age requirementBeneficiary must be 18 years of age or older

Current biologic statusBeneficiary must not be currently on another injectable biologic immunomodulator

OpenPayer

Pharmacy Prior Authorization Form — Injectable Biologic Immunomodulators for Plaque Psoriasis, Psoriatic Arthritis, and Behcet's Disease (oral ulcers)

Coverage Criteria for Biologic Therapy

Key Coding / Clinical Thresholds

Provider Actions and Prior Authorization Requirements

Background

Definitions and Diagnostic Thresholds