CurrentColorado Rocky Mountain Health PlansPolicy N/A

Intron A and Sylatron Washington Prior Authorization Request Form

A Washington-state prior authorization request form used by Colorado Rocky Mountain Health Plans (UnitedHealthcare) to request coverage for Intron A or Sylatron; it collects member, provider, diagnosis, prior therapy, and condition-specific checklist information to support PA decisions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyIntron A and Sylatron Washington Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Washington Intron A and Sylatron PA form with member, provider, clinical details, prior medication trials, and rationale; fax to 866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-940-7328fax number to submit form

800-310-6826phone for questions

24 hoursmin review time

Section CICD-10 field

Coverage Criteria and Condition Confirmation

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inv-01: Information and condition confirmation

Coverage consideration requires submission of the completed PA form with clinical justification and prior therapy history; the provider must indicate applicable diagnosis/condition and relevant checks such as absence of decompensated liver disease for Hepatitis B.

Form completion and clinical information: Completed Sections A–E including member information (Section A), provider information (Section B), medication details and ICD-10 diagnosis (Section C), prior medication trials (Section D), and explanation why preferred medications are unsuitable (Section E).

Required for any prior authorization request

Condition checklist: Provider must check one or more applicable conditions from the form checklist (e.g., Chronic Hepatitis B, myeloproliferative neoplasms, hairy cell leukemia, condylomata acuminata, AIDS-related Kaposi's sarcoma, leptomeningeal metastases, meningiomas, kidney cancer, follicular lymphoma, adult T-cell leukemia/lymphoma, mycosis fungoides/Sézary syndrome, desmoid tumors/aggressive fibromatosis, giant cell tumor of bone, malignant melanoma, systemic mastocytosis).

At least one applicable diagnosis expected

Hepatitis B special requirement: If treating Hepatitis B, provider must indicate whether the patient is without decompensated liver disease using the Hepatitis B section checkbox.

Specific checkbox present on form

The form does not present an explicit exclusions list. Instead, it requires the provider to indicate the presence or absence of a range of specific diagnoses and conditions by checking the applicable boxes on the form. When submitting a prior authorization request, include the completed form with clinical justification and any supportive details for the checked conditions so the reviewer can assess whether the requested therapy corresponds to an indicated condition.

Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Submit the completed Washington Intron A and Sylatron prior authorization form with member, provider, and clinical details. Allow at least 24 hours for review. Fax submissions to 866-940-7328 or call 800-310-6826 with questions.

Use the Washington Intron A and Sylatron PA form (fully completed).
Fax: 866-940-7328; Phone for questions: 800-310-6826.
Allow at least 24 hours for review; incomplete submissions may delay decision.

Documentation Required

Required Documentation

Required documentation must be provided with the PA form. Complete Sections A (member information) and B (provider information) and include all medical information in Section C. Provide the specific diagnosis and ICD-10 code, medication name, strength, directions for use, quantity, and pregnancy status if applicable.

Section A — Member: name, Member ID, contact, DOB, allergies, primary insurance, new vs continuation (if continuation provide start date), hospitalization/discharge status and dates.
Section B — Provider: name, M.D./D.O., address, phone, fax, NPI, specialty, office contact.
Section C — Medical information: medication, strength, directions, quantity, specific diagnosis and ICD-10 code, pregnancy status and due date if applicable.

Documentation Required

Document Prior Medication Trials

Document prior medication trials in Section D and provide reasons for failure or discontinuation. Explain why preferred alternatives are unsuitable in Section E and reference the patient's PDL when applicable.

Section D — List prior medication trials including name, strength, directions, dates of therapy, and reason for failure/discontinuation.
Section E — Explain why preferred medications would not meet the patient's needs; refer to the PDL at www.uhcprovider.com for preferred alternatives.

Denial Risk

Incomplete or Missing Information

Incomplete or missing information may delay or prevent a decision. Complete all pages of the PA form before faxing. Allow at least 24 hours for review and use the provided fax/phone contact details for submission or questions.

Incomplete submissions may delay the decision.
Complete all pages of the form to avoid delay.
Fax: 866-940-7328; Phone: 800-310-6826.

Therapy Background

Intron A (interferon alfa-2b) and Sylatron (peginterferon alfa-2b) are interferon-class therapies used for multiple indications. The PA form collects indication-specific information to support prior authorization decisions: providers must select the applicable diagnosis from the checklist (for example, Chronic Hepatitis B, various hematologic malignancies, cutaneous disorders, and solid tumor indications) and, when applicable, answer condition-specific questions such as whether the patient is without decompensated liver disease for Hepatitis B treatment. Complete clinical details and prior therapy history should accompany the request to facilitate timely review.

Condition Checklist and Assessment Fields

Conditions checklist

Chronic Hepatitis B InfectionCheckbox on form indicating presence of chronic Hepatitis B.

Myeloproliferative Neoplasms (MPNs)Includes examples such as essential thrombocythemia (ET), polycythemia vera (PV), or primary myelofibrosis (PM); checkbox on form.

Hairy Cell LeukemiaCheckbox on form indicating presence of hairy cell leukemia.

Condylomata Acuminata (genital or perianal)Checkbox on form indicating condylomata acuminata.

AIDS-Related Kaposi's SarcomaCheckbox on form indicating AIDS-related Kaposi's sarcoma.

Leptomeningeal MetastasesCheckbox on form indicating leptomeningeal metastases.

MeningiomasCheckbox on form indicating meningiomas.

Kidney CancerCheckbox on form indicating kidney cancer.

Follicular LymphomaCheckbox on form indicating follicular lymphoma.

Adult T-Cell Leukemia / LymphomaCheckbox on form indicating adult T-cell leukemia/lymphoma.

Mycosis Fungoides / Sézary SyndromeCheckbox on form indicating mycosis fungoides or Sézary syndrome.

Desmoid Tumors / Aggressive FibromatosisCheckbox on form indicating desmoid tumors (aggressive fibromatosis).

Giant Cell Tumor of the BoneCheckbox on form indicating giant cell tumor of the bone.

Malignant MelanomaCheckbox on form indicating malignant melanoma.

Systemic MastocytosisCheckbox on form indicating systemic mastocytosis.

Decompensated liver disease

Patient without decompensated liver diseaseProvider must indicate Yes or No to the question 'Is the patient without decompensated liver disease?' when treating Hepatitis B.

Treatment of Hepatitis B selectionForm includes a 'Treatment of Hepatitis B' Yes/No checkbox to trigger the decompensated liver disease question.

Provider signature and dateProvider signature and date lines follow the decompensated liver disease question on the form.

Initial Therapy Requirements

inv-11: Initial therapy requirements

For initial therapy requests, provide full member and provider details plus complete medication and diagnosis information as specified on the form.

Member and provider identification: Provide completed Section A (Member Information) and Section B (Provider Information) including names, member ID, contact details, and provider NPI/specialty.

Section A and B required for initial PA

Medication details: Specify medication name, strength, directions for use, and quantity as entered in Section C.

Section C medication fields must be completed

Diagnosis and coding: Provide a specific diagnosis and the ICD-10 code in the Section C ICD-10 CODE field.

ICD-10 code recorded in Section C

Prior therapies when applicable: Document prior medication trials (name, strength, directions, dates of therapy, and reason for failure/discontinuation) in Section D and explain why preferred alternatives are unsuitable in Section E.

Required when prior therapy history is relevant to the request

Continuation of Therapy Documentation

inv-12: Continuation of therapy documentation

The form captures whether the request is a new therapy or a continuation; documentation is required when continuation is requested.

New vs continuation indication: Indicate on Section A whether the requested medication is 'New' or 'Continuation of Therapy'.

Section A checkbox

Continuation start date: If 'Continuation of Therapy' is selected, provide the therapy start date as requested on the form.

Start date entry required for continuation requests

Medication name	Strength / directions	Dates of therapy	Reason for failure / discontinuation	Why preferred medications are unsuitable
(Enter each prior medication tried)
(Record strength and directions for each listed medication)
(Provide start and stop dates for each trial)
(State reason for failure or why therapy was stopped)
(Explain specifically why preferred alternatives on the PDL would not meet this patient’s needs)