Humira Prior Authorization Request Form printable pdf download

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Please note: All information below is required to process this request.

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Humira

Prior Authorization Request Form (Page 1 of 2)

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED

Member Information

Provider Information

(required)

Member Name:

Provider Name:

Insurance ID#:

NPI#:

Specialty:

Date of Birth:

Office Phone:

Street Address:

Office Fax:

City:

State:

Zip:

Office Street Address:

Phone:

City:

State:

Zip:

Medication Information

(required)

Medication Name:

Strength:

Dosage Form:

Continuation of therapy?  Yes  No If “YES”, answer the following:

Directions for Use:

Has member been on this medication in the last 180 days?*  Yes  No

Does the prescriber confirm that the medication has been effective in

 Check if requesting brand

treating the member’s medical condition?*  Yes  No

Clinical Information

(required)

Your patient's pharmacy benefit program is administered by UnitedHealthcare, which uses OptumRx for certain pharmacy benefit services. Your patient’s

benefit plan requires that we review certain requests for coverage with the prescribing physician. This includes requests for benefit coverage beyond plan

specifications. Please complete the following questions and then fax this form to the toll free number listed below. Upon receipt of the completed form,

prescription benefit coverage will be determined based on the benefit plan’s rules.

Select the requested medication below:

 Humira Pen

 Humira Crohn’s Disease Starter Package Prefilled Pen Kit

 Humira Pre-filled Syringe

 Humira Psoriasis Starter Package Prefilled Pen Kit

Select the diagnosis below:

 Active ankylosing spondylitis

 Active psoriatic arthritis

 Moderately to severely active Crohn’s disease

 Moderately to severely active rheumatoid arthritis

 Moderately to severely active polyarticular juvenile idiopathic arthritis

 Moderately to severely active ulcerative colitis

 Moderate to severe chronic plaque psoriasis

 Moderate to severe hidradenitis suppurativa

 Non-infectious uveitis

Other: _______________________________________________________ ICD-10 code(s): __________________________________

For all diagnoses, answer the following:

Select if the member will be receiving Humira in combination with the following:

 Biologic DMARD [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept)]

 Janus kinase inhibitor [e.g., Xeljanz (tofacintinib)]

 Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)]

 Not in combination with a biologic DMARD, janus kinase inhibitor, or PDE4 inhibitor

For moderately to severely active Crohn’s disease, also answer the following:

Has the member had an inadequate response to conventional therapies (examples include anti-inflammatory drugs, corticosteroids, oral

immunosuppressive agents) for Crohn’s disease or lost response/intolerance to Remicade (infliximab) therapy?  Yes  No

For moderately to severely active ulcerative colitis, also answer the following:

Has the member had prior or concurrent inadequate response to a therapeutic course of oral corticosteroids and/or immunosuppressants

(e.g., azathioprine, 6-mercaptopurine)?  Yes  No

______________________________________________________________________________________________________________

This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). The Provider

named above is required to safeguard PHI by applicable law. The information in this document is for the sole use of OptumRx. Proper consent to disclose

PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information

in this document is against the law. If you are not the intended recipient, please notify the sender immediately.

Office use only: Humira_UHCE&I_2017Sep-W