CurrentUnitedHealthcarePolicy N/A

Prior Authorization Request Form for Diabetes Supplies and Medications

A UnitedHealthcare prior authorization (PA) request form used by providers to request authorization for medications and diabetes test strips/meters (Washington-specific test strips section). It collects member, provider, clinical, and prior medication trial information to support PA decisions.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Request Form for Diabetes Supplies and Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and fax the entire PA form to 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+required data elements on form

180/monthinsulin-dependent quantity limit shown

180/90dnon-insulin dependent quantity limit

Prior Authorization Information / Documentation requirements

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ALL of the following

Completed Section A (Member Information) including member ID, DOB, contact information
Completed Section B (Provider Information) including NPI, specialty, phone/fax
Completed Section C (Medical Information) including medication, strength, directions, quantity, diagnosis and ICD-10 code
If continuation of therapy
- Indicate if request is new or continuation and if continuation, provide start date
If applicable to test strips (Washington)
- Document history of failure, contraindication, or intolerance to BOTH preferred test strip products (OneTouch Ultra and OneTouch Verio) if claiming failure to preferred
- Document whether patient is insulin dependent or pregnant
- Document if patient is on an insulin pump
- If requesting quantity above limits, provide clinical justification (e.g., IV insulin infusions, postprandial hyperglycemia, medication adjustment, MNT changes, exercise-related fluctuations)
Section D - Previous medication trials: list medication name, strength, directions, dates of therapy, and reason for failure/discontinuation where relevant
Provider signature and date

ANY of the following

Indicate if request is new or continuation and if continuation, provide start date

If applicable to test strips (Washington)

Document history of failure, contraindication, or intolerance to BOTH preferred test strip products (OneTouch Ultra and OneTouch Verio) if claiming failure to preferred
Document whether patient is insulin dependent or pregnant
Document if patient is on an insulin pump
If requesting quantity above limits, provide clinical justification (e.g., IV insulin infusions, postprandial hyperglycemia, medication adjustment, MNT changes, exercise-related fluctuations)

Required Provider Steps and Documentation

Prior Authorization

Submit completed PA form

Providers must complete and fax the entire prior authorization form (all relevant sections) to 866-940-7328 and allow at least 24 hours for review.

Complete all pages to avoid a delay in our decision
Allow at least 24 hours for review

Documentation Required

Document prior medication trials

When requesting medication authorization, list prior medication trials in Section D including medication name, strength, directions, dates of therapy, and reason for failure or discontinuation.

Include dates of therapy
Provide reason for failure/discontinuation

Documentation Required

Document test strip preferred-product failure (WA only)

For Washington test strip exceptions, document history of failure, contraindication, or intolerance to BOTH OneTouch Ultra and OneTouch Verio in Section D, including frequency of testing, date(s) of the trial, and reason for discontinuation.

Document failure/contraindication/intolerance to BOTH OneTouch Ultra and OneTouch Verio
Include frequency, date of trial, and reason for discontinuation in Section D

Documentation Required

Justify quantity overrides

If requesting quantities above the stated limits, provide a clinician narrative explaining the clinical circumstances requiring more frequent blood glucose testing.

Examples to justify overrides: IV insulin infusions, postprandial hyperglycemia requiring additional postprandial testing, medication adjustments, medical nutrition therapy (MNT) changes, exercise-related fluctuations
Explain other circumstances and confirm physician’s statement that greater quantity is required

Prior Authorization

Provider contact for questions

If you have questions about the form or prior authorization process, contact UnitedHealthcare Provider Services at 800-310-6826.

Clinical / Administrative Context

This document is an operational prior authorization (PA) request form used to collect the clinical and administrative information needed to evaluate requests for medications and diabetes testing supplies/meters. Providers are instructed to complete the entire form and fax it to 866-940-7328, allow at least 24 hours for review, and call 800-310-6826 with questions.

The form captures standard administrative details (member and provider identification, contact information, and insurance) and clinical information (medication name, strength, directions, quantity, diagnosis with ICD-10 code, pregnancy status, prior medication trials, and provider signature) necessary to support PA decisions.

For Washington members there is a dedicated Test Strips section that identifies the preferred meters and the instructions to obtain them directly from the manufacturer. The document names OneTouch Ultra and OneTouch Verio as the preferred test strip products and requires documentation of failure, contraindication, or intolerance to BOTH products if a non-preferred strip is requested. The Washington section also specifies quantity limits for test strips: 180 strips/90 days for non-insulin dependent members and 180 strips/month for insulin dependent members, with guidance to provide clinical justification when requesting quantities above these limits.

Scope Summary

This form serves as a UnitedHealthcare prior authorization (PA) request form used by providers to request authorization for medications and for diabetes test strips and meters (Washington-specific test strips section).

It collects member and provider administrative details (Section A and Section B), clinical medical information including medication name/strength/directions/quantity and diagnosis with ICD-10 code (Section C), and prior medication trial history with dates and reasons for failure or discontinuation (Section D) to support PA decisions.

The Washington-specific test strips section collects test-strip–related clinical information, documents whether the patient has failed or is intolerant to the preferred products (OneTouch Ultra and OneTouch Verio), whether the patient is insulin dependent or pregnant, and whether the patient uses an insulin pump; it also records the applicable quantity limits and asks for clinician justification when requesting quantities above those limits.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Request Form for Diabetes Supplies and Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and fax the entire PA form to 866-940-7328 and allow at least 24 hours for review.

SourceLink

On This Page

OpenPayer

Prior Authorization Request Form for Diabetes Supplies and Medications

Prior Authorization Information / Documentation requirements

Requested Diagnosis Code (Form field)

Required Provider Steps and Documentation

Clinical / Administrative Context

Defined Terms

Policy Update Changes

Scope Summary