CurrentUnitedHealthcarePolicy N/A

prior_authorization_request_form_rheumatoid_arthritis

A payer prior authorization request form to be completed by prescribers when requesting coverage for rheumatoid arthritis therapies (particularly injectable biologic immunomodulators). It captures beneficiary, prescriber, drug details and a checklist of clinical screening/criteria and prior therapy/contraindication questions required for authorization review.

Policy Summary

PayerUnitedHealthcare

Policyprior_authorization_request_form_rheumatoid_arthritis

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionPrescriber must complete beneficiary, prescriber, and drug information, answer all checklist items, and provide prescriber signature and date to request PA for rheumatoid arthritis therapy.

POLICY UPDATE CHANGES

No material clinical/coverage changes

8Checklist Items

3Therapy-history Options

1Mandatory Signature

Prior Authorization Request Form — Rheumatoid Arthritis (Summary)

This is a UnitedHealthcare prior authorization request form to collect clinical and administrative information needed to authorize coverage for rheumatoid arthritis therapies, particularly injectable biologic immunomodulators. The form focuses on key clinical screening areas including latent tuberculosis, Hepatitis B (HBsAg and core antibody), assessment of malignancy and major adverse cardiovascular event (MACE) risk, and evaluation of thrombotic risk. It also documents prior biologic therapy and specific trials or contraindications to agents such as TNF blockers, Enbrel (etanercept), and Humira (adalimumab).

Authorization Checklist for Rheumatoid Arthritis Therapy

Complete all applicable items; prescriber signature required.

Top-level checklist - complete all applicable items

Beneficiary has a diagnosis of Rheumatoid Arthritis

Checkbox: Yes/No

Beneficiary is not on another injectable biologic immunomodulator

Checkbox: Yes/No

Individual risks and benefits have been considered for malignancy and/or major adverse cardiovascular events (MACE)

Checkbox: Yes/No

Beneficiary is NOT considered to be at high risk for thrombosis

Checkbox: Yes/No

Beneficiary has been considered and screened for the presence of latent tuberculosis

Checkbox: Yes/No

Beneficiary has been tested with Hep B SAG and Core Ab

Checkbox: Yes/No

Beneficiary will NOT receive live vaccines during therapy

Checkbox: Yes/No

Therapy history

Beneficiary experienced therapeutic failure/inadequate response with at least one Tumor Necrosis Factor (TNF) blocker
Checkbox: Yes/No
Beneficiary is unable to receive TNF blockers due to contraindications or intolerabilities
Checkbox: Yes/No
Beneficiary had a trial and failure of Enbrel (etanercept) or Humira (adalimumab) or there is a clinical reason beneficiary cannot try Enbrel or Humira
Checkbox: Yes/No

Prescriber signature certifying accuracy (mandatory)

Signature and date required; statement about civil/criminal liability for falsification

Actions Required from Ordering Provider

Prior Authorization

Submit completed prior authorization form

Prescriber must complete beneficiary, prescriber, and drug information, answer all applicable checklist items, and provide prescriber signature and date to request prior authorization for rheumatoid arthritis therapy. The prescriber signature must be included on the form.

Documentation Required

Clinical documentation and screening tests

Document screening and clinical considerations prior to initiating therapy. Record latent tuberculosis screening and Hepatitis B tests (HBsAg and core antibody). Also document consideration of risks related to malignancy, major adverse cardiovascular events (MACE), thrombosis risk, and avoidance of live vaccines during therapy.

Latent tuberculosis screening
Hepatitis B HBsAg and core antibody (Core Ab) tests
Assessment of malignancy risk
Assessment of major adverse cardiovascular events (MACE) risk
Assessment of thrombosis risk
Plan to avoid live vaccines during therapy

Denial Risk

Missing prescriber signature

Prescriber signature is required on the form; failure to include the prescriber signature may result in the request being denied or returned.

Billing Rule

Pharmacy PA call center

For prior authorization assistance contact the Pharmacy PA Call Center at 1-855-258-1593.

Background and Scope

This UnitedHealthcare prior authorization form captures beneficiary, prescriber, and drug information and includes an authorization checklist of required clinical items for rheumatoid arthritis therapies. The form asks prescribers to confirm diagnosis, current therapy status (for example whether the beneficiary is on another injectable biologic immunomodulator), and to provide drug name, strength, quantity, and length of therapy. Screening priorities emphasized on the checklist include evaluation for latent tuberculosis, testing for Hepatitis B (HBsAg and core antibody), consideration of risks for malignancy and MACE, confirmation that the beneficiary is not at high risk for thrombosis, and that the beneficiary will not receive live vaccines during therapy. The form also documents prior biologic use and therapy history, including trials/failures of TNF blockers and specific agents such as Enbrel or Humira, and requires a prescriber signature and date to certify accuracy.

Policy Summary

PayerUnitedHealthcare

Policyprior_authorization_request_form_rheumatoid_arthritis

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionPrescriber must complete beneficiary, prescriber, and drug information, answer all checklist items, and provide prescriber signature and date to request PA for rheumatoid arthritis therapy.

On This Page

OpenPayer

prior_authorization_request_form_rheumatoid_arthritis

Prior Authorization Request Form — Rheumatoid Arthritis (Summary)

Authorization Checklist for Rheumatoid Arthritis Therapy

Actions Required from Ordering Provider

Background and Scope

Relevant Codes

Revision Timeline