CurrentUnitedHealthcarePolicy N/A

Specialty Medication Prior Authorization Cover Sheet

Forms and instructions governing submission of specialty pharmacy prior authorization requests and associated documentation for UnitedHealthcare members; applies to providers submitting PA requests for specialty medications.

Policy Summary

PayerUnitedHealthcare

PolicySpecialty Medication Prior Authorization Cover Sheet

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the entire prior authorization request form and fax it to 866-940-7328 for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-940-7328fax number to submit prior authorization requests

800-310-6826phone number for questions

24 hoursallow at least this time for review

Complete all pagesform completion requirement to avoid delays

Coverage Criteria

Example drug-specific criteria (Rubraca)

Policy Summary

PayerUnitedHealthcare

PolicySpecialty Medication Prior Authorization Cover Sheet

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the entire prior authorization request form and fax it to 866-940-7328 for review.

SourceLink

On This Page

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ALL of the following

ALL of the following
- Epithelial ovarian cancer
- Fallopian tube cancer
- Primary peritoneal cancer
Cancer has a deleterious BRCA mutation confirmed by an FDA‑approved diagnostic test (e.g., Foundation Focus CDxBRCA).
Patient has history of failure, contraindication, or intolerance to two or more chemotherapies (e.g., carboplatin or cisplatin).
ONE of
- Rubraca is to be used as maintenance therapy in individuals who are in complete or partial response to platinum‑based chemotherapy.
- Rubraca is being requested for a use supported by the NCCN Drugs and Biologics Compendium (if yes, list supported use).
For continuation requests: documentation must address whether the patient shows evidence of progressive disease while on Rubraca therapy and whether there is documentation of positive clinical response; if positive clinical benefit is claimed, list the benefit.

Provider Actions and Submission Instructions

Prior Authorization

Prior authorization submission instructions

Please complete the entire prior authorization request form and fax it to 866-940-7328. If you have questions, call 800-310-6826. This form contains multiple pages; complete all pages to avoid a delay in our decision. Allow at least 24 hours for review.

Documentation Required

Physician signature requirement

Physician signature is required on the cover sheet/prescription. By signing, the physician provides the specialty pharmacy with a prescription that can be used to facilitate dispensing and/or coordination of delivery for the requested medication. Delivery coordination requires the physician signature and completed provider and patient information.

Documentation Required

Drug-specific clinical criteria (example: Rubraca)

For drug-specific clinical criteria (example Rubraca): All requests — indicate diagnosis (epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer). Provide results of an FDA-approved BRCA mutation test (e.g., Foundation Focus CDxBRCA). Document history of failure, contraindication, or intolerance to two or more chemotherapies (for example, carboplatin or cisplatin); if applicable, complete the Previous Medication Trials section with medications, dates of therapy, and reasons for failure/discontinuation. State whether Rubraca is to be used as maintenance therapy in patients in complete or partial response to platinum-based chemotherapy. Confirm the requested use is supported by the NCCN Drugs and Biologics Compendium and list the supported use. For continuation of therapy: indicate whether there is evidence of progressive disease while on Rubraca and provide documentation of positive clinical response (describe positive clinical benefit). Attach all pertinent clinical information that supports the stated diagnosis and prior therapies tried and failed.

Definitions and Form Names

inv-08: Specialty Med Prior Authorization Cover Sheet

TermSpecialty Med Prior Authorization Cover Sheet

PurposeProvides provider and patient information, delivery instructions, and documents physician signature required for delivery coordination and specialty pharmacy dispensing.

Key requirementsMust include completed Provider Information, Patient Information, and Physician Signature to permit delivery coordination; ancillary supplies provided free at delivery.

Delivery optionsShip to physician's office or patient address; indicate date medication is needed and administration site (home health, self-administered, LTC, physician's office).

Confidentiality noticeElectronic fax transmission may contain confidential/privileged UnitedHealthcare information; unauthorized disclosure is prohibited and should be reported and destroyed if received in error.

inv-09: Prior Authorization Request Form

Form namePrior Authorization Request Form

Submission instructionPlease complete this entire form and fax it to: 866-940-7328.

Pages requirementThis form contains multiple pages. Please complete all pages to avoid a delay in our decision.

Processing timeAllow at least 24 hours for review.

QuestionsIf you have questions, please call 800-310-6826.

OpenPayer

Specialty Medication Prior Authorization Cover Sheet

Coverage Criteria

Diagnosis and Procedure Coding

Provider Actions and Submission Instructions

Definitions and Form Names