CurrentUnitedHealthcarePolicy N/A

Prior authorization form for biologic therapy for Crohn's disease and ulcerative colitis

This document is a prescriber-completed prior authorization request form to evaluate coverage of injectable biologic therapy for adult beneficiaries with Crohn's disease or ulcerative colitis. It affects prescribing providers and UnitedHealthcare benefit adjudicators processing biologic drug requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for biologic therapy for Crohn's disease and ulcerative colitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including patient and prescriber details, drug information, disease-specific checklist, TB and Hepatitis B screening, and documentation of trial/failure of Humira or clinical rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2disease-specific request sections (Crohn's, Ulcerative Colitis)

5required clinical screening checklist items per disease section

6patient/prescriber/drug information fields

Coverage Criteria for Biologic Therapy

Initial therapy criteria - Crohn's

Request for Crohn's Disease (Adult) — covered when ALL of the following are documented

Crohn_initial: 1. Diagnosis of moderate to severe Crohn's Disease must be confirmed on the form

checkbox item 1

Not_on_other_biologic: 2. Beneficiary is not currently on another injectable biologic immunomodulator

checkbox item 2

TB_screen: 3. Considered and screened for the presence of latent tuberculosis infection

checkbox item 3

HepB_screen:

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for biologic therapy for Crohn's disease and ulcerative colitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

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.

Initial therapy criteria - Ulcerative Colitis

Request for Ulcerative Colitis (Adult) — covered when ALL of the following are documented

UC_diagnosis: 1. Diagnosis of ulcerative colitis must be confirmed on the form

checkbox item 1

Not_on_other_biologic_UC: 2. Beneficiary is not currently on another injectable biologic immunomodulator

checkbox item 2

TB_screen_UC: 3. Considered and screened for the presence of latent tuberculosis

checkbox item 3

HepB_screen_UC: 4. Tested with Hep B SAG and Core Ab

checkbox item 4

Humira_trial_UC: 5. Trial and failure of Humira (adalimumab) or documented clinical reason beneficiary cannot try Humira

checkbox item 5

Provider Responsibilities and Prior Authorization Steps

Prior Authorization

Prior Authorization Form Completion

Prior authorization must be requested using the completed prior authorization form. The form must include patient and prescriber details, specific drug information (name, strength, quantity per 30 days, and requested length of therapy), and the prescriber's signature. Incomplete or missing forms will delay review and may result in denial.

Include drug name, strength, quantity per 30 days, and selected length of therapy (e.g., up to 30, 60, 90, 120, 180, or 365 days)
Provide beneficiary last name, first name, member ID, date of birth, and gender
Provide prescribing provider NPI and requester contact name and phone number
Prescriber signature and date are required

Step Therapy

Step Therapy / Trial Requirement

The form must include completed disease-specific checklists demonstrating required clinical history (for example, Crohn’s disease or ulcerative colitis sections). Where step therapy applies, document trial and failure of the required agent (e.g., Humira/adalimumab) or provide a clinical justification why the beneficiary cannot use that agent.

Document trial and failure of Humira (adalimumab) when required
If Humira was not tried, include a clinical reason why the beneficiary cannot try Humira (e.g., intolerance, contraindication, prior severe adverse reaction)
Complete relevant disease checklist items (diagnosis, prior biologic use, TB and Hepatitis B screening)

Documentation Required

Required Documentation

Required documentation must be submitted with the prior authorization request. Provide completed beneficiary demographics, prescribing provider NPI and contact information, drug name/strength/quantity/length of therapy, answers to disease-specific checklist items (including TB and Hep B screening), and the prescriber's signature.

Beneficiary: last name, first name, member ID, date of birth, gender
Prescriber: NPI number, requester contact name and phone number
Drug: name, strength, quantity per 30 days, selected length of therapy
Clinical: completed disease-specific checklist answers (diagnosis, prior biologic use, TB screening, Hep B SAG/Core Ab)
Prescriber signature and date

Denial Risk

Triggers for Denial

Applications may be denied for missing or incomplete information. Common triggers for denial include absence of the prescriber signature, incomplete beneficiary or prescriber fields, missing drug details or length of therapy selection, and unanswered disease-specific checklist items (including lack of documentation for TB and Hep B screening or missing step-therapy/trial information).

Missing prescriber signature or date
Incomplete beneficiary demographics or missing member ID
Missing prescriber NPI or contact information
Unspecified drug strength, quantity per 30 days, or length of therapy
Unanswered disease-specific checklist items (diagnosis, TB screening, Hep B testing, step-therapy/trial of Humira)

Definitions and Clinical Thresholds

Moderate to severe Crohn's Disease / Ulcerative Colitis — required clinical confirmations

Clinical diagnosis confirmationPrescriber must confirm the beneficiary has the specified diagnosis (moderate to severe Crohn's disease or ulcerative colitis) using the checkbox on the form.

Not currently on another injectable biologicCheckbox requires confirmation that the beneficiary is not currently on another injectable biologic immunomodulator.

Tuberculosis screeningForm requires that the beneficiary has been considered and screened for latent tuberculosis infection before initiating biologic therapy.

Hepatitis B testingForm requires testing with Hepatitis B surface antigen (SAG) and core antibody (Core Ab).

Humira (adalimumab) trial or rationaleMost actionable: documentation of trial and failure of Humira (adalimumab) or a documented clinical reason the beneficiary cannot try Humira is required on the form.

OpenPayer

Prior authorization form for biologic therapy for Crohn's disease and ulcerative colitis

Coverage Criteria for Biologic Therapy

Provider Responsibilities and Prior Authorization Steps

Background

Definitions and Clinical Thresholds