CurrentUnitedHealthcarePolicy N/A

Prior authorization form for biologic therapy for rheumatoid arthritis

This document is a prescriber-completed prior authorization request form used by the payer to evaluate coverage for injectable biologic immunomodulator therapy for beneficiaries with rheumatoid arthritis.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for biologic therapy for rheumatoid arthritis

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescriber must confirm diagnosis of rheumatoid arthritis and document prior therapy trials (methotrexate or another DMARD), TB and Hepatitis B screening, and prior biologic trial/failure or clinical reason the patient cannot try specified biologics.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8distinct form sections / items to complete

6predefined length-of-therapy choices

TB/HepBscreening questions present

Step itemstep therapy requirement

Coverage Criteria and Form Confirmations

Authorization criteria (form confirmations)

Coverage consideration requires prescriber confirmation of the following items on the form

Diagnosis and screening: Beneficiary has a diagnosis of rheumatoid arthritis AND has been considered and screened for latent tuberculosis AND has been tested for Hepatitis B (Hep B sAg and core antibody).

Form items 1, 3, and 4 must be answered affirmatively.

Prior therapy (DMARD): Either therapeutic failure/inadequate response with methotrexate or at least one disease-modifying antirheumatic drug (e.g., leflunomide, hydroxychloroquine, minocycline, sulfasalazine) OR inability to receive methotrexate/DMARD due to contraindication or intolerance.1 of 2

Document response to item 5 or item 6 on the form.

Prior biologic step therapy:

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for biologic therapy for rheumatoid arthritis

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

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 Required Actions and Documentation

Prior Authorization

Prior Authorization Requirements

Prior authorization is required. The prescriber must confirm the beneficiary diagnosis and provide documentation of prior therapies and treatment details. Include the diagnosis (e.g., Rheumatoid Arthritis), prior therapy trials or reason for exemption, and full drug order information (drug name, strength, dose, quantity, and requested length of therapy).

Include beneficiary demographics and ID
Provide prescribing provider NPI and requester contact name/phone
Document drug name, strength, quantity per 30 days, and length of therapy requested (e.g., up to 30/60/90/120/180/365 days)
Prescriber signature and date are required

Step Therapy

Step Therapy / Prior-Agent Trial

Step therapy is enforced. Document a therapeutic failure or inadequate response to methotrexate or at least one other DMARD (for example: leflunomide, hydroxychloroquine, minocycline, sulfasalazine). If methotrexate or a DMARD was not tried, provide clinical justification (e.g., contraindication or intolerance). Also document prior trial and failure of Enbrel (etanercept) or Humira (adalimumab) when required, or provide a clinical reason why these agents cannot be used.

Document specific agents tried, dates of therapy, and reason for discontinuation (inefficacy, adverse effects)
If exempting from methotrexate/DMARD trial, state contraindication or intolerance explicitly
If asserting inability to use Enbrel or Humira, provide clinical rationale

Denial Risk

Potential Denial Triggers

Applications may be denied if required information is missing or incomplete. Common denial triggers include absent or unclear diagnosis, lack of documented DMARD or methotrexate trial (or missing justification for exemption), missing documentation of prior Enbrel/Humira trial when required, and failure to document screening for latent tuberculosis or hepatitis B where applicable. Ensure the prescriber-signed attestation is included.

Missing beneficiary diagnosis or inconsistent diagnosis documentation
No documentation of methotrexate or DMARD trial or missing contraindication/intolerance justification
No documentation of latent TB screening or Hepatitis B testing (HBsAg and core Ab)
Omitted prescriber signature or date

OpenPayer

Prior authorization form for biologic therapy for rheumatoid arthritis

Coverage Criteria and Form Confirmations

Provider Required Actions and Documentation

Key Definitions and Screening Items

Policy Background