CurrentUnitedHealthcarePolicy N/A

Specialty Medication Prior Authorization Cover Sheet

This document is a cover sheet and accompanying prior authorization request form that must be submitted for specialty pharmacy medication prior authorization requests for UnitedHealthcare members; it affects prescribing providers, specialty pharmacies, and UnitedHealthcare prior authorization reviewers.

Policy Summary

PayerUnitedHealthcare

PolicySpecialty Medication Prior Authorization Cover Sheet

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the Specialty Medication Prior Authorization Cover Sheet with the Pharmacy Prior Authorization Medication Fax Request Form to UnitedHealthcare (fax 866-940-7328) and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+form fields

24/7submission contact

24hreview minimum

Alecensadrug example

Coverage and Medical Necessity Criteria

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Clinical documentation and drug-specific criteria

Form requests clinical information to establish medical necessity and prior therapy history. For certain drugs (example: Alecensa) additional disease- and biomarker-specific prompts are requested.

Clinical documentation and prior therapy history must be provided as part of the request.

ALL of the following

Confirm diagnosis of non-small cell lung cancer (NSCLC).
Indicate whether the medication is being requested for a use supported by the NCCN Drugs and Biologics Compendium; if yes, list the supported response.
Disease status (check one)
- Metastatic
- Recurrent

Document prior medication trials: list medication name, strength, directions, dates of therapy, and reason for failure or discontinuation.

ALL of the following

For continuation requests, provide initiation date and last dose date.
Provide documentation of positive clinical response to therapy (if applicable) and specify the positive response.
Indicate whether the patient shows evidence of progressive disease while on Alecensa therapy (Yes/No).

ALL of the following

Indicate tumor ALK (anaplastic lymphoma kinase) status (ALK-positive: Yes/No).

Submission, Signature, and Drug-Specific Requests

Prior Authorization

Submission instructions and contact

Submit this Specialty Medication Prior Authorization Cover Sheet along with a completed Pharmacy Prior Authorization Medication Fax Request Form. Fax the prior authorization request form and this cover sheet to 866-940-7328. For questions, call 800-310-6826 or refer to www.uhcprovider.com for medication fax request forms. Allow at least 24 hours for review after submission.

Fax: 866-940-7328
Phone: 800-310-6826
Refer to www.uhcprovider.com for forms
Allow ≥ 24 hours for review

Documentation Required

Signature and delivery coordination

Physician signature is required on the cover sheet to facilitate dispensing and delivery coordination. Delivery coordination also requires completion of Provider Information and Patient Information sections on the cover sheet. Indicate the desired ship-to location and date medication is needed. All necessary ancillary supplies are provided free of charge to the patient at the time of delivery.

Required: Physician Signature
Complete: Provider Information and Patient Information
Ship to options: Physician's Office or Patient's Address
Specify: Date medication is needed (MM/DD/YYYY)
Medication administered: Home Health / Self-Administered / LTC / Physician's Office
Ancillary supplies provided free at delivery

Prior Authorization

Drug-specific authorization prompts (Alecensa)

For Alecensa (alectinib) requests, confirm and document the following: diagnosis of non-small cell lung cancer (NSCLC); that the requested use is supported by the NCCN Drugs and Biologics Compendium (include specific supported indication if yes); disease status (metastatic or recurrent); and tumor ALK status. For continuation of therapy, document whether the patient has shown progressive disease while on Alecensa and whether there is a documented positive clinical response (describe response if yes).

Does the patient have a diagnosis of NSCLC? (Yes/No)
Is the requested use supported by NCCN? If yes, list supported response
Is the disease metastatic or recurrent? (check applicable)
Is the tumor ALK-positive? (Yes/No)
For continuation: Evidence of progressive disease on Alecensa? (Yes/No)
For continuation: Documented positive clinical response to Alecensa? If yes, describe response

Form Definitions and Field Guidance

Physician signature

Field labelPhysician Signature

PurposeRequired on cover sheet to facilitate dispensing and delivery coordination

Related requirementDelivery coordination requires completed 'Provider Information' and 'Patient Information' in addition to the signature

New Start / Continuation

Field labelIs this medication a New Start?

New Start optionCheckbox: Yes

Continuation optionCheckbox: No; if continuation selected provide initiation date, date of last dose, and documentation of positive clinical response

Policy Summary

PayerUnitedHealthcare

PolicySpecialty Medication Prior Authorization Cover Sheet

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Specialty Medication Prior Authorization Cover Sheet

Coverage and Medical Necessity Criteria

Diagnosis and Coding Information

Submission, Signature, and Drug-Specific Requests

Form Definitions and Field Guidance