CurrentUnitedHealthcarePolicy N/A

Prior authorization criteria for injectable biologic immunomodulators for selected immunology/rheumatology indications

Document is a UnitedHealthcare beneficiary/prescriber prior authorization checklist governing coverage decisions for injectable biologic immunomodulators for indications including ankylosing spondylitis, Crohn's disease (adult and pediatric), plaque psoriasis (adult), psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization criteria for injectable biologic immunomodulators for selected immunology/rheumatology indications

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization checklist including diagnosis, prior therapy trials and failures, infection screening results (latent TB and Hep B SAg and core Ab), and the prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7indications covered by this form

3required infection screening items (TB, Hep B SAg, Hep B core Ab)

2required prior biologic trials named most commonly (Enbrel, Humira)

Prior Authorization Criteria for Injectable Biologic Immunomodulators

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General prescriber verification items (applies across indications)

Prior authorization requests must include the following general items:

ALL of the following

Beneficiary identifying information completed (name, ID, DOB, gender)
Prescribing provider NPI and contact information provided
Prescriber signature and date (mandatory)
Drug name, strength, quantity per 30 days, and length of therapy specified

Ankylosing Spondylitis — approval criteria