Humira Prior Authorization Request Form (Page 2 of 2) in pdf

Humira

Prior Authorization Request Form (Page 2 of 2)

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

Reauthorization:

If this is a reauthorization request, answer the following questions:

Is there documentation the member has had a positive clinical response to Humira therapy?  Yes  No

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 (apremilast)]

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

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

Quantity Limit Requests:*

For rheumatoid arthritis requesting weekly dosing, has the member had inadequate response to every other week dosing?  Yes  No

For Crohn’s disease or ulcerative colitis requesting weekly dosing, has the member had inadequate response to every other week dosing

after a minimum of 24 weeks of therapy?  Yes  No

For requests requiring re-initiation of therapy/induction dosing for Crohn’s disease, plaque psoriasis, ulcerative colitis, hidradenitis

suppurativa, or uveitis, has the member experienced interruption in therapy for medical reasons (e.g., surgery, infection)?  Yes  No

Prescriber attestation:

Does the prescriber attest that the information provided is true and accurate to the best of their knowledge and understand that United

Healthcare may perform a routine audit and request the medical information necessary to verify the accuracy of the information

provided?  Yes  No

Prescriber’s signature: ________________________________________________________

Date: ____________________________

*May not apply to all plans

Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to

this review?

______________________________________________________________________________________________________________

Please note:

This request may be denied unless all required information is received within established timelines.

This request may be denied unless all required information is received.

For urgent or expedited requests please call 1-800-711-4555.

This form may be used for non-urgent requests and faxed to 1-800-527-0531.

______________________________________________________________________________________________________________

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