CurrentUnitedHealthcarePolicy N/A

NC Medicaid Pharmacy Prior Approval Request — Injectable Biologic Immunomodulators

Prior authorization form and criteria for coverage of injectable biologic immunomodulators for multiple inflammatory conditions for North Carolina Medicaid beneficiaries; directed at prescribers requesting PA. It covers documentation and condition-specific checklist requirements.

Policy Summary

PayerUnitedHealthcare

PolicyNC Medicaid Pharmacy Prior Approval Request — Injectable Biologic Immunomodulators (coverage criteria for multiple inflammatory indications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed NC Medicaid Pharmacy Prior Approval Request form with prescriber signature and required condition-specific checklists including prior therapy failures, TB screening, and Hepatitis B testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16document chunks/pages

Multipleindications covered

TB & Hep Bscreening required

PA Call Centercontact info

Indication-specific Coverage Criteria

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.

Ankylosing Spondylitis

Request for Ankylosing Spondylitis — coverage requires ALL of the following to be documented:

Ankylosing Spondylitis PA criteria: 1) Diagnosis of Ankylosing Spondylitis; 2) Beneficiary is not currently on another injectable biologic immunomodulator; 3) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 4) Beneficiary has been tested with Hep B SAG and Core Ab; 5) Beneficiary has experienced inadequate symptom relief from treatment with at least two NSAIDs OR is unable to receive NSAIDs due to contraindications; 6) Clinical evidence of severe or rapidly progressing disease (if applicable)

Crohn's Disease (Adult and Pediatric)

Request for Crohn's Disease (Adult and Pediatric) — coverage requires ALL of the following:

Crohn's Disease PA criteria: 1) Diagnosis of moderate to severe Crohn's Disease; 2) Beneficiary is not currently on another injectable biologic immunomodulator; 3) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 4) Beneficiary has been tested with Hep B SAG and Core Ab

Polyarticular Juvenile Idiopathic Arthritis

Request for Polyarticular Juvenile Idiopathic Arthritis (PJIA) — coverage requires ALL of the following:

PJIA PA criteria: 1) Diagnosis of Polyarticular Juvenile Idiopathic Arthritis; 2) Beneficiary is not currently on another injectable biologic immunomodulator; 3) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 4) Beneficiary has been tested with Hep B SAG and Core Ab; 5) Beneficiary has tried one systemic corticosteroid (e.g., prednisone, methylprednisolone) or methotrexate, leflunomide, or sulfasalazine with inadequate response OR is unable to take these therapies due to contraindications; 6) Document PJIA subtype enthesitis related arthritis if applicable

Plaque Psoriasis (Adult)

Request for Plaque Psoriasis (Adult) — coverage requires ALL of the following:

Plaque Psoriasis PA criteria: 1) Documented definitive diagnosis of moderate-to-severe chronic plaque psoriasis; 2) Age ≥18 years; 3) Beneficiary is not currently on another injectable biologic immunomodulator; 4) Beneficiary has been considered and screened for the presence of latent tuberculosis infection (not required for Otezla); 5) Beneficiary has been tested with Hep B SAG and Core Ab (not required for Otezla); 6) Body surface area (BSA) involvement ≥3% OR involvement of palms/soles/head/neck/genitalia causing disruption in normal daily activities and/or employment; 7) Failed to respond to, or unable to tolerate, phototherapy AND ONE of acitretin (Soriatane), methotrexate, or cyclosporine OR has contraindications to these treatments

Psoriatic Arthritis

Request for Psoriatic Arthritis — coverage requires ALL of the following:

Psoriatic Arthritis PA criteria: 1) Documented definitive diagnosis of psoriatic arthritis; 2) Age ≥18 years (or ≥2 years for Simponi Aria); 3) Beneficiary is not currently on another injectable biologic immunomodulator; 4) Beneficiary has been considered and screened for the presence of latent tuberculosis infection (not required for Otezla); 5) Beneficiary has been tested with Hep B SAG and Core Ab (not required for Otezla); 6) Documented inadequate response or inability to take methotrexate

Rheumatoid Arthritis

Request for Rheumatoid Arthritis — coverage requires ALL of the following:

Rheumatoid Arthritis PA criteria: 1) Diagnosis of rheumatoid arthritis; 2) Beneficiary is not currently on another injectable biologic immunomodulator; 3) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 4) Beneficiary has been tested with Hep B SAG and Core Ab; 5) Therapeutic failure/inadequate response with methotrexate or at least one disease-modifying antirheumatic drug (e.g., leflunomide, hydroxychloroquine, minocycline, sulfasalazine) OR unable to receive methotrexate/DMARD due to contraindication or intolerance; 6) Clinical evidence of severe or rapidly progressing disease (if applicable)

Ulcerative Colitis (Adult and Pediatric)

Request for Ulcerative Colitis (Adult and Pediatric) — coverage requires ALL of the following:

Ulcerative Colitis PA criteria: 1) Diagnosis of ulcerative colitis; 2) Beneficiary is not currently on another injectable biologic immunomodulator; 3) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 4) Beneficiary has been tested with Hep B SAG and Core Ab

Hidradenitis Suppurativa

Request for Hidradenitis Suppurativa (ages ≥12) — coverage requires ALL of the following:

Hidradenitis Suppurativa PA criteria: 1) Diagnosis of moderate to severe hidradenitis suppurativa; 2) Age ≥12 years; 3) Beneficiary is not currently on another injectable biologic immunomodulator; 4) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 5) Beneficiary has been tested with Hep B SAG and Core Ab

Non-infectious Intermediate Posterior Panuveitis

Request for Non-infectious Intermediate Posterior Panuveitis (ages ≥2) — coverage requires ALL of the following:

Panuveitis PA criteria: 1) Diagnosis of non-infectious intermediate posterior panuveitis; 2) Age ≥2 years; 3) Beneficiary is not currently on another injectable biologic immunomodulator; 4) Beneficiary has been considered and screened for the presence of latent tuberculosis infection; 5) Beneficiary has been tested with Hep B SAG and Core Ab

Otezla (apremilast) is an oral phosphodiesterase‑4 inhibitor referenced on the PA form for certain inflammatory skin and joint indications. For plaque psoriasis and psoriatic arthritis the form explicitly indicates that screening for latent tuberculosis infection and testing for hepatitis B surface antigen and core antibody are not required when Otezla is the agent being requested. This exception should be noted on the PA request so reviewers understand that TB and Hepatitis B testing fields may remain unfilled when Otezla is the intended therapy.

Step	Requirement
1
Documentation of failure, intolerance, or contraindication to prior conventional therapies before initiation of an injectable biologic immunomodulator (examples listed on the PA form include: ≥2 NSAIDs for Ankylosing Spondylitis; phototherapy plus one systemic agent [acitretin, methotrexate, or cyclosporine] for plaque psoriasis; methotrexate or another DMARD for rheumatoid arthritis).

Provider Submission Requirements and Denial Risks

Prior Authorization

Prior Authorization Form and Signature Required

Prior Authorization form and prescriber signature required. Completed beneficiary, prescriber, and drug information must be submitted on the prior authorization form with the prescriber's signature. Incomplete or unsigned forms may delay processing or result in denial.

Submit completed PA form including beneficiary name, ID, DOB, gender.
Include prescriber NPI and requester contact name/phone.
Provide drug name, strength, quantity per 30 days, and length of therapy (select days).
Prescriber signature is mandatory (see signature certification).

Documentation Required

Completed Beneficiary, Prescriber and Drug Information Required

The request must include completed beneficiary and prescriber information and full drug details. Absence of documented diagnosis or missing required patient/prescriber data may result in denial.

Beneficiary: last name, first name, beneficiary ID #, date of birth, gender.
Prescriber: prescribing provider NPI #, requester contact name and phone number.
Drug: drug name, strength, quantity per 30 days, and selected length of therapy.

Documentation Required

Condition-specific Documentation and Prior Therapy Requirements

Condition-specific checkboxes on the form must be completed to document diagnosis, prior therapies, contraindications/intolerances, and screening tests (e.g., TB and Hepatitis B). Many indications require documentation of prior conventional therapy failure or intolerance before approval.

Use the diagnosis-specific sections (e.g., Ankylosing Spondylitis, Crohn's Disease, Plaque Psoriasis) and complete all relevant checkboxes.
Document prior conventional therapy failures/intolerances where required (for example, ≥2 NSAIDs for ankylosing spondylitis).
Indicate contraindications or inability to receive standard therapies when applicable.
Confirm TB screening and Hep B testing checkboxes where requested.

Denial Risk

Denial Risk for Missing Diagnosis, Prior Therapy, or Screening

Failure to document required prior therapies, screening tests, or a definitive diagnosis increases risk of denial. Review the diagnosis section for indication-specific prior therapy rules (e.g., phototherapy and systemic agents for plaque psoriasis).

Absence of a documented definitive diagnosis may result in denial.
For plaque psoriasis, failure to document prior phototherapy and at least one systemic agent (or documented contraindication/intolerance) may result in denial.
Requests lacking documentation of TB screening or Hep B testing where indicated may be denied.

Prior Authorization

Prescriber Signature and Certification

Prescriber certification: the prescriber must sign the form affirming accuracy and completeness. Unsigned certification will lead to processing delays or denial.

(Prescriber Signature Mandatory) I certify that the information provided is accurate and complete to the best of my knowledge.
Pharmacy PA Call Center: 1-855-258-1593

OpenPayer

NC Medicaid Pharmacy Prior Approval Request — Injectable Biologic Immunomodulators

Indication-specific Coverage Criteria

Initial Therapy Authorization Requirements

Step Therapy Requirements

Provider Submission Requirements and Denial Risks

Quantity Limits and Coding Fields

Policy Background and Scope

Definitions and Form Fields