CurrentUnitedHealthcarePolicy N/A

Prior authorization form for plaque psoriasis medications

Form used by prescribers to request prior authorization for systemic or biologic treatments for adult patients with moderate-to-severe chronic plaque psoriasis. Affects prescribers and UnitedHealthcare pharmacy prior authorization reviewers.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for plaque psoriasis medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with beneficiary and prescriber information, requested drug details, and answers to the plaque psoriasis clinical questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

adultage group specified

>=3%BSA threshold

TB & Hep Binfectious screening

Cosentyx/Enbrel/Humirabiologic step

phototherapy +1 systemicprior therapies

Coverage Criteria

Initial Authorization Criteria

Covered when ALL of the following are met (as indicated on the form):

Adult diagnosis and severity: Documented definitive diagnosis of moderate-to-severe chronic plaque psoriasis AND beneficiary is 18 years of age or older

See form questions 1 and 2

Prior treatments and contraindications: Beneficiary is not currently on another injectable biologic immunomodulator AND has been considered/screened for latent TB (except for Otezla) AND has been tested for Hep B surface antigen and core antibody

See form questions 3-5

Severity location or extent: Either BSA involvement >=3% OR involvement of palms/soles/head/neck/genitalia causing disruption in daily activities/employmentBSA >=3%

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for plaque psoriasis medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with beneficiary and prescriber information, requested drug details, and answers to the plaque psoriasis clinical questions.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Submission Requirements

Prior Authorization

Form submission requirements

Submit this completed prior authorization form including beneficiary demographics, prescriber NPI and contact information, requested drug details (name, strength, quantity per 30 days, and length of therapy), and the prescriber signature and date. Incomplete forms or missing required fields may delay processing or result in denial.

Beneficiary demographics (last name, first name, ID #, DOB, gender)
Prescribing provider NPI and requester contact name/phone/ext
Drug name, strength, quantity per 30 days, length of therapy (select days or specify)
Prescriber signature and date (mandatory)

Step Therapy

Biologic trial / step therapy

The form requires documentation of a trial and failure of listed biologic agents or a clear clinical reason why those agents cannot be used. Providers must indicate whether the beneficiary has had a trial and failure of Cosentyx, Enbrel, or Humira, or document the clinical rationale for not using these agents.

Document trial and failure of Cosentyx, Enbrel, and/or Humira — or provide clinical reason(s) beneficiary cannot try these agents
If documenting failure, include dates, durations, and reason for discontinuation (lack of efficacy, adverse reaction, contraindication)

Denial Risk

Potential missing clinical criteria (denial risk)

Ensure the form documents all listed clinical criteria and supporting information. Missing documentation of key clinical criteria (definitive diagnosis of moderate-to-severe chronic plaque psoriasis, age ≥18 years, required severity measures such as BSA ≥3% or involvement of sensitive/body areas, prior phototherapy and systemic therapy trial or contraindication) may place the request at risk for denial.

Definitive diagnosis of moderate-to-severe chronic plaque psoriasis (explicitly stated)
Age ≥ 18 years documented
Body Surface Area (BSA) involvement ≥ 3% or involvement of palms/soles/head/neck/genitalia with functional impact
Documentation of prior phototherapy and ONE systemic therapy (acitretin/Soriatane, methotrexate, or cyclosporine) trial and outcome, or documented contraindication/intolerance
TB screening and Hepatitis B surface antigen/core antibody testing results (unless not required for the requested agent, e.g., Otezla)

Documentation Required

Required form fields and signature

The prescriber must sign the attestation certifying accuracy of the information. A missing prescriber signature or incomplete required fields (see "Form submission requirements") will delay review or lead to denial.

Signed prescriber attestation (mandatory) with date
Attestation statement confirms accuracy and acknowledges legal liability for falsification or omission

Background

Background: This form collects clinical information to support prior authorization decisions for systemic or biologic therapies in adults with moderate-to-severe chronic plaque psoriasis. It captures a documented definitive diagnosis, age (≥18 years), current biologic use, infectious disease screening (latent TB and Hepatitis B surface antigen and core antibody), extent of disease including BSA ≥3% or special-site involvement, prior treatment history (phototherapy plus one systemic agent), and prior trial/failure of or contraindication to specified biologics (Cosentyx, Enbrel, Humira). Responses to these items are used to determine whether the beneficiary meets the form’s coverage criteria for systemic/biologic treatment.

Definitions

Moderate-to-severe chronic plaque psoriasis — Documented definitive diagnosis and severity

Definitive diagnosis requiredForm question 1: documented definitive diagnosis of moderate-to-severe chronic plaque psoriasis is required

Adult age requirementBeneficiary must be 18 years of age or older (form question 2)

Severity assessment — BSAAt least 3% BSA involvement qualifies as moderate-to-severe (form question 6)

Severity assessment — special sitesInvolvement of palms, soles, head/neck, or genitalia causing disruption in daily activities/employment qualifies regardless of BSA (form question 7)

Related treatment screeningForm also requires documentation of prior treatments and screening (e.g., phototherapy failure, systemic agents, TB and Hep B testing) to support the diagnosis and treatment plan

OpenPayer

Prior authorization form for plaque psoriasis medications

Coverage Criteria

Coding and Severity Metrics

Provider Actions & Submission Requirements

Background

Definitions