CurrentUnitedHealthcarePolicy N/A

Florida Medicaid prior authorization for non-preferred diabetic supplies (DSP)

This form and policy govern prior authorization requests for non-preferred diabetic supplies for Florida Medicaid beneficiaries; it affects prescribers, pharmacies, and Medicaid recipients requesting coverage for non-preferred diabetic products.

Policy Summary

PayerUnitedHealthcare

PolicyFlorida Medicaid prior authorization for non-preferred diabetic supplies (DSP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Florida Medicaid Non-Preferred Diabetic Supply prior authorization form in full; fax to 1-866-940-7328 or contact PA Call Center at 1-855-258-1593.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 Yearlength of authorization

Fax: 1-866-940-7328submission fax number

1-855-258-1593pharmacy PA phone

Medical records (up to 5y)documentation request

Authorization Criteria

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Authorization criteria

Prior authorization will be considered when the following information and documentation are provided:

Form completed in full; incomplete forms may be returned.

Provide prescriber and pharmacy identifying information: prescriber name, NPI, phone, fax; pharmacy name, Medicaid provider number, phone, fax.

Requested product details: product name, quantity, refills, and directions must be provided.

If the request is for a continuous glucose monitor (CGM): indicate that the request is for a CGM (Yes/No) and state whether the patient is currently receiving insulin (Yes/No).

Provide medical justification explaining why a preferred product cannot be used for this recipient.

Include required supporting documentation: copies of medical records (e.g., diagnostic evaluations and recent documentation for up to five years).

Coding and CGM Screening

No codes specified on formmixed

No codes listed

Insulin requirement for CGM — form question

Form fieldAsks ‘Is this request for a continuous glucose monitor (CGM)?’ with Yes/No options.

Insulin treatment follow-upIf CGM = Yes, form asks ‘If yes, is the patient currently receiving insulin?’ with Yes/No options.

Decision relevanceCGM requests trigger additional insulin-related information to document treatment status.

Submission & Documentation Requirements

Prior Authorization

Submit completed Florida Medicaid DSP prior authorization form

Complete and submit the Florida Medicaid Non-Preferred Diabetic Supply (DSP) prior authorization form in full; an incomplete form may be returned. Fax the completed form to 1-866-940-7328 or contact the Pharmacy PA Call Center at 1-855-258-1593.

Length of authorization indicated on form: 1 Year
Include prescriber and pharmacy contact information (prescriber name, NPI, phone, fax; pharmacy name, Medicaid provider number, phone, fax)

Documentation Required

Include medical justification and supporting medical records

Provide medical justification explaining why a preferred product cannot be used and include all required medical records submitted for review.

Medical justification statement as requested on the form
Attach copies of medical records (diagnostic evaluations and recent documentation for five years)
Prescriber's signature and date are required

Form Field Definitions

CGM — form field definition indicating insulin question

CGM field definitionForm includes a discrete field asking whether the request is for a continuous glucose monitor (CGM) with Yes/No responses.

Associated insulin questionWhen CGM is selected Yes, a follow-up Yes/No field asks whether the patient is currently receiving insulin.

PurposeCaptures device type requested and the patient’s insulin-treatment status for authorization review.

Medical justification — required explanation and supporting records

Medical justification requirementForm states ‘Medical justification is required as to why a preferred product cannot be used for this recipient.’

Supporting recordsRequired for review: all copies of medical records (e.g., diagnostic evaluations and recent documentation for five years).

Signature and datePrescriber’s signature and date are required on the form to attest to the justification provided.