CurrentUnitedHealthcarePolicy N/A

Neuromuscular Agents — Lupus Agents prior authorization form

Prior authorization documentation and medical necessity criteria for neuromuscular/lupus agents (including voclosporin/Lupkynis) for UnitedHealthcare members; intended for prescribers seeking authorization or continuation of therapy for lupus/SLE and lupus nephritis.

Policy Summary

PayerUnitedHealthcare

PolicyNeuromuscular Agents — Lupus Agents prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the entire prior authorization form (Sections A–E), attach chart notes and lab results showing active disease, provide baseline and current assessments as applicable, include prescriber signature and specialty, and fax to 866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+form fields to complete for request

24–72allow at least 24 hours for review (form instruction)

1fax submissions required (866-940-7328)

1call for questions (800-310-6826)

Authorization Requirements and Medical Necessity

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.

General Prior Authorization / Medical Necessity Submission Requirements

Authorization will be considered when required documentation and clinical criteria are provided:

ALL of the following

Completed prior authorization form (all sections) including Sections A–E
Form must be faxed to 866-940-7328
Chart notes documenting diagnosis and clinical course
Laboratory results demonstrating active disease (e.g., labs consistent with SLE or lupus nephritis)
Functional assessments baseline and current if applicable (SLE indices listed)
If SLE and not lupus nephritis
Prescriber signature, prescriber specialty, and date

Initial or Continuation of Therapy — Condition and Diagnostic Criteria

Request (new or continuation) must meet diagnostic criteria depending on indication:

Diagnosis must be ONE of the following

Lupus nephritis (active class III or IV, with or without class V) confirmed by renal biopsy
Systemic Lupus Erythematosus (SLE) with laboratory results showing active disease and autoantibody-positive tests (e.g., ANA or anti-dsDNA)
Other — specify diagnosis (requires supporting documentation)

For continuation requests

Documentation demonstrating disease stability or a positive clinical response from baseline measurements
Form asks: does patient have clinical documentation demonstrating disease stability or positive response?

Special vocational criteria for Voclosporin (Lupkynis)

Additional items required if request is for voclosporin:

ALL of the following

Confirm whether patient has history of belimumab treatment for lupus nephritis that was ineffective, not tolerated, or contraindicated
Form asks to indicate No/Yes and explain if yes
Confirm patient will not use voclosporin in combination with tacrolimus or cyclophosphamide
Yes/No question on form

Prescriber specialty requirement

Specialist involvement expected for certain indications:

ANY of the following

Prescribed by or in consultation with a rheumatologist or nephrologist (form asks Yes/No)

Concomitant therapy reporting

Form requires documentation of concurrent lupus therapies

ALL of the following

List current use of belimumab (if request is for voclosporin)
List current corticosteroid therapy (name and dose)
List current immunosuppressant therapy (e.g., mycophenolate, cyclophosphamide, azathioprine)
List use of hydroxychloroquine and NSAIDs if applicable

Required Laboratory/Clinical Thresholds

Estimated Glomerular Filtration Rate (eGFR)Provide baseline and current eGFR (mL/min/1.73m2) with dates

Urinary protein-to-creatinine ratioProvide baseline and current values with dates

What the Provider Must Do

Prior Authorization

Submit completed prior authorization form

Complete the entire prior authorization form (Sections A–E), attach chart notes, laboratory results demonstrating active disease, and any baseline and current functional assessments if applicable. Include the prescriber signature, prescriber specialty, and date. Fax the completed packet to 866-940-7328.

Documentation Required

Provide diagnostic confirmation for lupus nephritis

For requests for lupus nephritis, include renal biopsy documentation that confirms active class III or IV disease; class V may be present with class III or IV. Ensure the biopsy result is attached to the submission.

Documentation Required

Provide prior therapy history for voclosporin requests

When requesting voclosporin, indicate whether the patient has a history of belimumab use for lupus nephritis that was ineffective, not tolerated, or contraindicated, and confirm the patient will not use voclosporin in combination with tacrolimus or cyclophosphamide.

Documentation Required

Report concomitant lupus therapies

List current concomitant lupus therapies and provide dates and doses where applicable.

Belimumab (if request is for voclosporin): indicate use/status and dates/doses
Corticosteroids (e.g., prednisone, methylprednisolone): list name, dose, and dates
Immunosuppressants (e.g., mycophenolate, cyclophosphamide, azathioprine): list name, dose, and dates
Hydroxychloroquine: list use and dates/doses
NSAIDs: list use and dates/doses

Denial Risk

Incomplete submission may delay or deny authorization

Failure to provide all required form fields, chart notes, laboratory results, functional assessments (when applicable), or the prescriber signature/specialty/date may delay review or result in denial of the authorization request.

Clinical and Administrative Context

This prior authorization form is used to document clinical information to support medical necessity for neuromuscular and lupus agents, including agents used to treat systemic lupus erythematosus (SLE) and lupus nephritis such as voclosporin (Lupkynis). The form must be completed in full and faxed to the number listed; allow at least 24 hours for review to avoid delays in decision-making.

The form requests objective measures of renal function and disease activity to establish baseline status and enable assessment of response or stability. Specifically it requires baseline and, for continuation requests, current values and dates for the urinary protein-to-creatinine ratio and the estimated glomerular filtration rate (eGFR) in mL/min/1.73 m2.

For SLE (non‑renal) indications, when renal measures are not applicable the form asks for baseline and current assessments using validated disease activity or functional assessment tools (for example SLEDAI, BILAG, SLAM, SLE Index Score, PGA, or SLICC Damage Index) to document disease activity and treatment response.

When the request is for voclosporin, the form additionally asks about prior use of belimumab for lupus nephritis (whether it was ineffective, not tolerated, or contraindicated) and requires confirmation that voclosporin will not be used in combination with tacrolimus or cyclophosphamide.

Complete submissions must include chart notes, laboratory results demonstrating active disease, applicable functional assessments (baseline and current), prescriber signature and specialty. Failure to provide all required fields or documentation may delay review or result in denial.

OpenPayer

Neuromuscular Agents — Lupus Agents prior authorization form

Authorization Requirements and Medical Necessity

Diagnosis Code Guidance

What the Provider Must Do

Clinical and Administrative Context

Key Terms

Policy Updates