CurrentUnitedHealthcarePolicy N/A

Antidiabetics, Amylin Analogs prior authorization form (Washington)

Prior authorization request form and clinical criteria checklist for amylin analog antidiabetic medications for members in Washington under UnitedHealthcare. Governs submission requirements, clinical questions to document diagnosis, prior medication trials, and continuation criteria to obtain coverage approval.

Policy Summary

PayerUnitedHealthcare

PolicyAntidiabetics, Amylin Analogs prior authorization form (Washington)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete the entire prior authorization request form (Sections A–E and Clinical Drug-Specific Information) and fax to 866-940-7328; allow at least 24 hours for review.

POLICY UPDATE CHANGES

No material changes — brief indicates has_material_change = false; no policy updates provided.

1Form type (PA request)

7Clinical data fields required (sections A–E plus clinical checklist)

Coverage Summary

This is a UnitedHealthcare prior authorization request form for amylin analog antidiabetic agents for members in Washington. The form and accompanying clinical checklist are used to evaluate requests and determine medical necessity.

Coverage stance: covered_with_criteria. The document governs submission requirements and clinical questions (Sections A–E plus the clinical/drug-specific checklist) that must be completed to support initial and continuation authorization decisions.

Medical Necessity Criteria

Initial Authorization / Clinical Eligibility

Coverage considered when ALL of the following are provided:

ALL of the following

Completed prior authorization request form submitted (Sections A–E and clinical/drug-specific information).
Form must be completed entirely and faxed to 866-940-7328.
Documented diagnosis: Type 1 diabetes mellitus OR Type 2 diabetes mellitus OR other (must list).
Diagnosis and ICD-10 code must be provided in Section C.
Indication supportive findings (at least one typical scenario)
- Failure to achieve desired glycemic control despite optimal insulin therapy (Yes/No; must be 'Yes' to support this criterion).
  Form asks if patient failed to achieve desired glycemic control despite optimal insulin therapy; answer must be 'Yes'.
- Currently receiving optimal mealtime insulin or continuous insulin infusion (insulin pump).
  Form records current use of optimal mealtime insulin or insulin pump; presence supports combined regimen.
- Patient has gastroparesis or requires medication to stimulate GI motility (e.g., metoclopramide or erythromycin).
- Poor compliance with current insulin regimen.
- Poor compliance with self-blood glucose monitoring.
- Hemoglobin A1c > 9% within the last 3 months.> 9% within the last 3 months
- Recurrent severe hypoglycemia that required assistance during the past 6 months.
Previous medication trials section completed with reason for failure and dates of therapy (Section D).
Provider must document prior medication trials and reasons for discontinuation.
Provider signature and date present on the prior authorization request form.

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Continuation of Therapy

Requests for continuation require ALL of the following:

ALL of the following

Indication for continuation clearly documented (Continuation of Therapy box checked and start date provided if applicable).
Documentation of positive clinical benefit from therapy.
Form asks 'Is there documentation of positive clinical benefit?' — must be answered 'Yes'.
Updated relevant clinical information (e.g., HbA1c, hypoglycemia events, compliance) to justify continued coverage.

Provider Actions

Prior Authorization

Submit Prior Authorization Form

Complete Sections A–E and the Clinical Drug-Specific Information on the prior authorization request form and fax the entire form to 866-940-7328. Allow at least 24 hours for review of the submission.

Fax: 866-940-7328

Documentation Required

Document Diagnosis and ICD-10 Code

Provide the specific diagnosis and the corresponding ICD-10 code in Section C of the form. Indicate whether the diagnosis is Type 1 diabetes mellitus, Type 2 diabetes mellitus, or Other (and supply details if Other is selected).

ICD-10 CODE

Documentation Required

Provide Prior Medication Trials

Complete Section D with prior medication trial details including medication names, strengths, directions for use, dates of therapy, and the reason for discontinuation to demonstrate prior trials or failures of preferred alternatives.

Documentation Required

Document Positive Clinical Benefit for Continuation

For continuation requests, include documentation showing positive clinical benefit from the therapy and provide the therapy start date when the Continuation of Therapy option is selected.

Billing Rule

Provider Signature Required

The prior authorization form must be signed and dated by the provider. Unsigned or undated forms may delay processing or result in denial of the authorization.

Background

This UnitedHealthcare prior authorization request form is specific to Amylin Analogs for Washington members and collects member and provider details (Sections A and B), medication and diagnosis information including an ICD-10 code (Section C), prior medication trials with dates and reasons for discontinuation (Section D), and additional explanation/justification (Section E) to determine medical necessity and continued coverage. The form must be completed in full and faxed to the number provided for review.

Amylin analog: Class of antidiabetic medication (e.g., pramlintide) used as adjunctive therapy to insulin for glycemic control; exact agent to be specified on form.

OpenPayer

Antidiabetics, Amylin Analogs prior authorization form (Washington)

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions

Background