CurrentUnitedHealthcarePolicy N/A

prior_authorization_form_for_specific_drugs

This document is a payer-specific prior authorization request form used by prescribers to request coverage for certain injectable biologic drugs for multiple indications (Crohn's disease, plaque psoriasis adult and pediatric, psoriatic arthritis, ulcerative colitis). It captures beneficiary, prescriber, and drug information and documents required clinical checkboxes (diagnosis, age, prior therapy trials, TB and hepatitis screening).

Policy Summary

PayerUnitedHealthcare

Policyprior_authorization_form_for_specific_drugs

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete beneficiary, prescriber, and drug information, check required clinical boxes for the applicable indication, and provide prescriber signature (mandatory).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form remains a payer-specific prior authorization request capturing existing clinical and screening prerequisites.

5Indications covered on form

>=3%Psoriasis BSA threshold

Policy overview & scope

This UnitedHealthcare pharmacy prior authorization request form is used by prescribers to request coverage for certain injectable biologic and systemic therapies for multiple autoimmune/inflammatory indications, including Crohn's disease, plaque psoriasis (adult and pediatric), psoriatic arthritis, and ulcerative colitis. The form captures beneficiary identifying information (name, ID, DOB, gender), prescriber information (NPI, requester contact and phone), and drug information (drug name, strength, quantity per 30 days, length of therapy). It also requires completion of indication-specific clinical checkboxes documenting diagnosis, age criteria where applicable, prior-therapy trials or documented reasons those therapies cannot be used, and infection screening (confirmation that the beneficiary has been considered/screened for latent tuberculosis and tested for Hepatitis B surface antigen (HBsAg) and core antibody (Core Ab)).

Key metadata and thresholds

PayerUnitedHealthcare

Policyprior_authorization_form_for_specific_drugs

Policy NumberN/A

StatusCURRENT

Effective Date/Next Review

Threshold - BSA for plaque psoriasis>= 3%

This is a payer-specific prior authorization form that operationalizes the prior-therapy and infection-screening prerequisites referenced in UnitedHealthcare pharmacy policies by collecting required clinical data and prescriber attestations (including a mandatory prescriber signature) needed to support coverage decisions for injectable biologic and systemic therapies.

Approval prerequisites by indication

General form-level required attestations

Prescriber must complete required fields and attest to accuracy; prescriber signature mandatory.

ALL of the following

Beneficiary information: Beneficiary identifying information completed (last name, first name, beneficiary ID, DOB, gender)
Prescriber information completed (NPI, requester contact info, phone)
Drug information completed (drug name, strength, quantity per 30 days, length of therapy)
Prescriber signature and date (Prescriber Signature Mandatory)

Request for Crohn's Disease (Adult) - Approval prerequisites