CurrentUnitedHealthcarePolicy N/A

Prior authorization form for injectable biologic immunomodulator (multiple indications)

A pharmacy prior-approval request form used to request coverage of an injectable biologic immunomodulator for specific diagnoses (NOMID, Rheumatoid Arthritis, DIRA). Captures beneficiary, prescriber, drug, therapy length, indication-specific screening and trial requirements. Intended for prescribers submitting PA to UnitedHealthcare (national).

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for injectable biologic immunomodulator (multiple indications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior-approval form with beneficiary, prescriber and drug details, confirm infection screening and prior therapy trials as required, and include the mandatory prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3indications listed on the form

mandatoryprescriber signature requirement

tuberculosis & Hepatitis Brequired infection screening documented for each indication

Policy Summary & Scope

This form is a pharmacy prior-approval request used to request coverage of an injectable biologic immunomodulator for specific diagnoses: Neonatal‑onset multisystem inflammatory disease (NOMID), Rheumatoid Arthritis (RA), and Deficiency of Interleukin‑1 Receptor Antagonist (DIRA). It captures beneficiary, prescriber and drug information (including prescribing provider NPI, beneficiary name/ID/DOB/gender, drug name, strength, quantity per 30 days, and requested length of therapy). Intended users are prescribers submitting prior authorization requests to UnitedHealthcare for national coverage. Coverage is provided with criteria and will be considered when the indication‑specific requirements on the form are met.

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Prior Authorization Criteria by Indication

General submission requirements (applies to all indications on form)

PA request will be considered when ALL of the following are documented:

ALL of the following

Prescriber information provided (including prescribing provider NPI)
Beneficiary information provided (name, ID, DOB, gender)
Drug name, strength, quantity per 30 days, and requested length of therapy provided
Prescriber signature is present (mandatory)
Prescriber signature is required on the form

Request for Neonatal Onset Multisystem Inflammatory Disease (NOMID)

Coverage considered when ALL of the following are met:

ALL of the following

Diagnosis of neonatal-onset multisystem inflammatory disease (NOMID) is documented
Beneficiary is not currently on another injectable biologic immunomodulator
Form asks to confirm beneficiary is not on another injectable biologic immunomodulator
Beneficiary has been considered and screened for latent tuberculosis infection
Screening for latent TB must be documented
Beneficiary has been tested for Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab)

Request for Rheumatoid Arthritis

Coverage considered when ALL of the following are met:

ALL of the following

Diagnosis of Rheumatoid Arthritis is documented
Beneficiary is not currently on another injectable biologic immunomodulator
Beneficiary has been considered and screened for latent tuberculosis infection
Beneficiary has been tested for Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab)
prior DMARD or methotrexate requirement

Request for Deficiency of Interleukin-1 Receptor Antagonist (DIRA)

Coverage considered when ALL of the following are met:

ALL of the following

Diagnosis of Deficiency of Interleukin-1 Receptor Antagonist (DIRA) is documented
Beneficiary is not currently on another injectable biologic immunomodulator
Beneficiary has been considered and screened for latent tuberculosis infection
Beneficiary has been tested for Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab)

What Providers Must Do

Prior Authorization

Submit completed PA form with mandatory prescriber signature

Complete and submit the pharmacy prior approval form with all beneficiary, prescriber (including prescribing provider NPI) and drug fields filled; indicate the applicable indication-specific responses and confirm required infection screening and prior-therapy trials where asked. Ensure the prescriber signs and dates the form — prescriber signature is mandatory before submission.

Provide beneficiary name, ID, DOB and gender (Beneficiary Information).
Provide prescribing provider NPI and requester contact information (Prescriber Information).
Provide drug name, strength, quantity per 30 days and select length of therapy (Drug Information).
Answer indication-specific checklist items for NOMID, RA or DIRA (Request sections).
Sign and date the form (Signature of Prescriber — Prescriber Signature Mandatory).

Documentation Required

Infection screening documentation

Document that the beneficiary has been considered and screened for latent tuberculosis and record Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab) test results for the indicated diagnosis; these items are required for each indication on the form.

NOMID section asks: “Has the beneficiary been considered and screened for the presence of latent tuberculosis infection?” and “Has the beneficiary been tested with Hep B SAG and Core Ab?”
RA section asks the same TB and Hep B screening/test questions.
DIRA section asks the same TB and Hep B screening/test questions.

Documentation Required

Prior therapy documentation for Rheumatoid Arthritis

For Rheumatoid Arthritis requests, document therapeutic failure or inadequate response to methotrexate or at least one DMARD (or document contraindication/intolerance to these agents), and document trial and failure of etanercept (Enbrel) or adalimumab (Humira) or a clinical reason the beneficiary cannot try them.

Answer item 5: therapeutic failure/inadequate response with methotrexate or at least one DMARD (e.g., leflunomide, hydroxychloroquine, minocycline, sulfasalazine).
Answer item 6: inability to receive methotrexate or DMARD due to contraindication or intolerance, if applicable.
Answer item 8: trial and failure of Enbrel or Humira, or document clinical reason beneficiary cannot try Enbrel or Humira.

Clinical & Administrative Background

This is a pharmacy prior‑approval form for injectable biologic immunomodulators intended for the specific inflammatory and genetic conditions listed on the form: NOMID, Rheumatoid Arthritis, and DIRA. The form is structured to ensure required administrative data are provided (beneficiary and prescriber details, drug name/strength/quantity, and the requested length of therapy up to 365 days), and it requires the prescriber’s signature prior to submission.

For all indications the form emphasizes infection screening and safety checks: providers must document that the beneficiary has been considered and screened for latent tuberculosis infection and that Hepatitis B testing (both Hep B SAG and Core Ab) has been performed. For Rheumatoid Arthritis the form additionally requires documentation of prior therapy — either therapeutic failure or inadequate response to methotrexate or at least one DMARD (for example, leflunomide, hydroxychloroquine, minocycline, sulfasalazine), or a documented contraindication/intolerance to these agents — and documentation of a trial and failure of a tumor necrosis factor (TNF) inhibitor (etanercept/Enbrel or adalimumab/Humira) or a clinical reason why these cannot be used.

Prescriber signature is mandatory on the form to certify the accuracy of the information and to complete the prior approval request.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for injectable biologic immunomodulator (multiple indications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Prior authorization form for injectable biologic immunomodulator (multiple indications)

Policy Summary & Scope

Prior Authorization Criteria by Indication

What Providers Must Do

Procedure / Diagnosis Codes

Clinical & Administrative Background

Defined Terms

Policy Changes