CurrentColorado Rocky Mountain Health PlansPolicy N/A

Insulin Pen Needles and Syringes Prior Authorization Request (Washington)

A Washington-specific prior authorization request form and instructions for coverage review of insulin pen needles and syringes for Colorado Rocky Mountain Health Plans members via UnitedHealthcare processes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInsulin Pen Needles and Syringes Prior Authorization Request (Washington)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete entire prior authorization form (Sections A–E), include required documentation, and fax to 866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursReview time

6/dayQuantity limit

866-940-7328Fax

800-310-6826Phone

Coverage Criteria

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Complete Sections A–E with member, provider, medication, diagnosis (ICD-10), and previous medication trials information.

Document history of failure to the preferred BD insulin pen needle or syringe when applicable (Section D).

Provide explanation why preferred medications/products would not meet patient needs (Section E) and reference the patient's PDL at www.uhcprovider.com for preferred alternatives.

If requesting greater than the quantity limit (6 of each pen needles and syringes per day), include physician confirmation of need and rationale; provider signature and date required (Section showing physician confirmation).

Fax the completed prior authorization form to 866-940-7328 and allow at least 24 hours for review; contact 800-310-6826 with questions.

Diagnosis and Coding

Diagnosis codingICD-10

ICD-10

ICD-10 code required in Section C

inv-03: Quantity limit — 6 of each (pen needles and syringes) per day

Daily quantity limit6 of each (pen needles and syringes) per day

Applies toBoth pen needles and syringes

Exception processPhysician may confirm need for greater quantity due to more frequent insulin delivery (form includes physician confirmation section)

Form locationQuantity limit note appears on the Prior Authorization Request Form under QUANTITY LIMITS

Provider Actions / Prior Authorization Submission

Prior Authorization

Submit Prior Authorization Request

Complete the entire Insulin Pen Needles and Syringes Prior Authorization Request Form, Sections A–E, including member, provider, medical information (including ICD-10 diagnosis in Section C), previous medication trials, rationale why preferred products are not suitable, and quantity justification. Fax the completed form to 866-940-7328 and allow at least 24 hours for review; call 800-310-6826 with questions.

Include ICD-10 code in Section C (Diagnosis).
If continuation of therapy, include start date in Section A.
Complete Section D for prior medication trials and Section E for explanation why preferred medications would not meet patient needs.

Documentation Required

Documentation Requirements

Document any history of failure to the preferred BD insulin pen needle or syringe and provide the rationale why the patient is unable to use the preferred BD product when applicable. If requesting greater than the quantity limit, include physician confirmation that the patient requires a greater quantity and the supporting rationale.

If patient has history of failure to preferred BD product, complete Section D (Previous Medication Trials).
List rationale for inability to use preferred BD product as prompted in Section D/Section E.
For quantities above the limit, obtain provider signature confirming need and date on the form.

Definitions

inv-06: Daily quantity limit for pen needles and syringes is 6 of each per day — quantity limit.

Daily maximum per device type6 per day for pen needles; 6 per day for syringes

Documentation for >6/dayPhysician confirmation required on the form that patient needs greater quantity due to more frequent insulin delivery

Form actionComplete and sign the Prior Authorization Request Form section for quantity limits to request exception

Reference noteQuantity limit statement is provided in the QUANTITY LIMITS section of the form