CurrentUnitedHealthcarePolicy N/A

Topical Anti-Inflammatories (North Carolina) Prior Authorization Form - Community Planopen_in_new

A prescriber-completed prior authorization request form for topical anti-inflammatory medications (e.g., Eucrisa, Elidel, pimecrolimus, Protopic, tacrolimus, Opzelura) for UnitedHealthcare Community Plan in North Carolina. Captures beneficiary, prescriber, drug, trial/failure, age, diagnosis, and renewal questions to support PA decisions.

Policy Summary

PayerUnitedHealthcare

PolicyTopical Anti-Inflammatories (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the PA form, providing beneficiary, prescriber, drug, trial/failure, age, diagnosis, and renewal information and list failed medications or contraindications where required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief (has_material_change=false).

6Distinct drug groups covered

>=2Opzelura prior trial classes required

Policy snapshot

This prescriber-completed prior authorization form is used to request coverage for topical anti-inflammatory medications (e.g., Eucrisa, Elidel, pimecrolimus, Protopic, tacrolimus, Opzelura) and captures the clinical and administrative information needed to evaluate a PA request. The form collects beneficiary identifiers and demographics, prescriber contact and NPI, and specific drug details including name, strength, quantity per 30 days, and requested length of therapy.

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To support clinical review, the form documents prior trials and failures (for example, whether the beneficiary tried and failed at least one prescription topical corticosteroid and any failed preferred topical anti-inflammatory medications), any documented adverse reactions or contraindications that preclude trial of a topical corticosteroid, age and diagnosis criteria specific to the requested product (age cutoffs vary by drug), and renewal information including disease improvement/stability and serious treatment-related adverse events. The prescriber must complete all relevant items and sign and date the form.

ScopeA prescriber-completed prior authorization request form for topical anti-inflammatory medications (e.g., Eucrisa, Elidel, pimecrolimus, Protopic, tacrolimus, Opzelura) for UnitedHealthcare Community Plan in North Carolina. Captures beneficiary, prescriber, drug, trial/failure, age, diagnosis, and renewal questions to support PA decisions.

PolicyTopical Anti-Inflammatories Prior Authorization Form (North Carolina) - Community Plan

PayerUnitedHealthcare

StatusCURRENT

Policy NumberN/A

Effective / Next ReviewEffective: N/A; Last review: N/A; Next review: N/A

Prior authorization questions and decision logic

General Prior Authorization Questions for Eucrisa, Elidel, Pimecrolimus, Protopic, Tacrolimus

Questions 1-7 to document prior trials, contraindications, and age criteria:

ALL of the following

Beneficiary tried and failed on at least one prescription topical corticosteroid
Yes/No checkbox (Question 1)
Documented adverse reaction or contraindication that precludes trial of 1 topical corticosteroid
Yes/No and free-text if yes (Question 2)
Age requirement depending on drug
- Eucrisa: beneficiary is 3 months old or older
  Yes/No checkbox (Question 5)
- Elidel, pimecrolimus cream, Protopic 0.03%, tacrolimus 0.03%: beneficiary is 2 years of age or older
  Yes/No checkbox (Question 6)
- Protopic 0.1% and tacrolimus 0.1%: beneficiary is 18 years of age or older
  Yes/No checkbox (Question 7)

What the prescriber must do

Prior Authorization

Prior authorization required

A prior authorization form is required to request topical anti-inflammatory medications. Document prior trials, contraindications, age and diagnosis criteria, and other clinical information on the form to support the PA decision.

Eucrisa
Elidel
Pimecrolimus
Protopic
Tacrolimus
Opzelura

Documentation Required

Complete PA form fields

Prescriber must complete beneficiary, prescriber, and drug information, answer all relevant trial/failure, age, diagnosis, and renewal questions on the form, and sign and date the form.

Prescriber signature is mandatory

Documentation Required

List failed medications or contraindications

For non-preferred medication requests and for Opzelura prior-trial requirements, the prescriber must list failed medications or contraindications in the free-text fields on the form.

Form purpose and clinical notes

The form collects trial and failure information and free-text lists of failed medications or contraindications so reviewers can confirm that preferred therapies or required prior classes were attempted before approving non-preferred agents or Opzelura (for Opzelura, trial/failure or contraindication to ≥2 specified classes is required).

Age, diagnosis, contraindication, and renewal questions are included to ensure the beneficiary meets product-specific eligibility (for example: Eucrisa ≥ 3 months; Elidel/pimecrolimus/Protopic 0.03%/tacrolimus 0.03% ≥ 2 years; Protopic 0.1%/tacrolimus 0.1% ≥ 18 years; Opzelura ≥ 12 years with mild–moderate atopic dermatitis) and to document ongoing benefit or any serious adverse events at renewal.

Policy Summary

PayerUnitedHealthcare

PolicyTopical Anti-Inflammatories (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Topical Anti-Inflammatories (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy snapshot

Prior authorization questions and decision logic

What the prescriber must do

Who and what this form applies to

Form purpose and clinical notes

Document changes