CurrentUnitedHealthcarePolicy N/A

SGLT2 inhibitors prior authorization

This document governs prior authorization requests for SGLT2 inhibitor drugs and their combinations for UnitedHealthcare beneficiaries, covering both initial and continuation requests and applying to prescribers requesting coverage. It affects coverage decisions for preferred and non-preferred SGLT2 products.

Policy Summary

PayerUnitedHealthcare

PolicySGLT2 inhibitors prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization checklist and attach medical documentation demonstrating improvement and required prior trials for non-preferred products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial+Continuationrequest types covered on form

Up to 365days of therapy selectable on form

Preferred vs Non-preferredproduct categories referenced

Coverage Criteria

inv-01: Initial Requests

Covered when ALL of the following are met

Initial SGLT2 authorization: 1) Beneficiary has a documented diagnosis relevant to SGLT2 use (e.g., heart failure and/or Type 2 diabetes). 2) Documentation of prior trial and failure or insufficient response to metformin therapy OR a documented contraindication/adverse event to metformin. 3) Documentation of established atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease and any relevant comorbidities (e.g., obesity, hypertension, dyslipidemia, albuminuria) as applicable.all

Responses captured on initial request form (questions 1–6)

inv-02: Non-preferred Product Requirements

Additional requirement for non-preferred products

Non-preferred SGLT2 authorization: Applicant must demonstrate trial and failure or insufficient response to at least two preferred SGLT2 products OR provide a clinical reason why preferred products cannot be tried.

Policy Summary

PayerUnitedHealthcare

PolicySGLT2 inhibitors prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization checklist and attach medical documentation demonstrating improvement and required prior trials for non-preferred products.

SourceLink

On This Page

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Provider Actions & Requirements

Prior Authorization

Prior authorization clinical checklist — Prior authorization requires completion of the initial request checklist

Prior authorization requires completion of the initial request checklist. The requester must document diagnoses (e.g., heart failure, Type 2 diabetes), prior metformin trial/response, contraindications or adverse events to metformin, and comorbid conditions as indicated. Complete all applicable clinical questions on the form and attach supporting medical records.

Initial request checklist (diagnosis of heart failure, Type 2 diabetes, prior metformin trial/response, contraindication/adverse event to metformin, ASCVD/CKD history)
Attach medical records supporting diagnoses and prior therapy

Step Therapy

Step therapy for non-preferred products — For non-preferred SGLT2 products, the requester must document trial and failure or insufficient response to at least two preferred products

For non-preferred SGLT2 products, the requester must document trial and failure or insufficient response to at least two preferred products unless there is a documented clinical reason the preferred products cannot be used. List the preferred products tried, dates, and reason for failure or intolerance.

Document trial and failure or insufficient response to ≥ 2 preferred products
If preferred products cannot be tried, provide clinical rationale and supporting documentation
Include names of preferred products tried and dates

Documentation Required

Continuation documentation — Attach medical documentation showing beneficiary improvement and evidence that individual clinical goals are being met for continuation requests

Attach medical documentation showing beneficiary improvement and evidence that individual clinical goals are being met for continuation requests. Requests without objective documentation of clinical benefit or progress toward goals may be denied.

Medical documentation demonstrating clinical improvement on therapy
Evidence that individualized clinical goals set by the provider are being met
Documentation of ongoing progress toward treatment goals

Documentation Required

Required form fields and signature — Prescriber must complete beneficiary and prescriber information sections including beneficiary identifiers, prescriber NPI and contact, drug details, and sign/date the form

Prescriber must complete beneficiary and prescriber information sections on the form, provide drug details (name, strength, quantity per 30 days, length of therapy), and sign and date the form. Prescriber NPI and contact information are required. The prescriber signature certifies accuracy and completeness; unsigned requests will be returned or denied.

Beneficiary identifiers: last name, first name, beneficiary ID, DOB, gender
Prescribing provider NPI and requester contact name/phone
Drug details: name, strength, quantity per 30 days, length of therapy
Prescriber signature and date (mandatory)

Denial Risk

Non-preferred product trial requirement — Failure to document trial and failure or insufficient response to at least two preferred products when requesting non-preferred SGLT2 agents

Failure to document trial and failure or insufficient response to at least two preferred products when requesting a non-preferred SGLT2 product will result in denial unless a clear clinical reason why preferred products cannot be used is provided and documented.

If requesting non-preferred product, provide list of ≥ 2 preferred products tried with dates and reasons for failure
If preferred products are contraindicated or not appropriate, include clinical justification and supporting records

Definitions

Non-preferred product

DefinitionAn SGLT2 inhibitor product requiring additional justification, including prior trials of at least two preferred products or a documented clinical reason why preferred products cannot be tried.

Required documentation for non-preferred requestsDocument trial and failure or insufficient response to at least two preferred SGLT2 products or provide a clinical reason preferred products cannot be used.

Form question locationExplicit question on the initial request form asks whether the beneficiary tried and failed or had insufficient response to at least two preferred products.

Applies toBoth initial and continuation requests when the requested product is non-preferred.

OpenPayer

SGLT2 inhibitors prior authorization

Coverage Criteria

Coding & Duration

Provider Actions & Requirements

Background

Definitions