CurrentUnitedHealthcarePolicy N/A

Gender Affirming Care (GAC) - Maryland Prior Authorization Form

A Maryland-specific prior authorization form and documentation checklist for medication-based gender-affirming care (GAC) used by UnitedHealthcare to request review and approval for initial and reauthorization requests; applies to providers seeking coverage for GAC medications for UnitedHealthcare members in Maryland.

Policy Summary

PayerUnitedHealthcare

PolicyGender Affirming Care (GAC) - Maryland Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Maryland GAC prior authorization 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.

12 monthsauthorization duration

24 hoursminimum review time

866-940-7328fax

800-310-6826phone

Coverage Criteria

Initial and Reauthorization criteria

Authorization (Initial and Reauthorization) is granted when the documented requirements and monitoring/attestation items are provided as follows:

Documentation of medical necessity for gender affirming care from a somatic healthcare professional (e.g., primary care) or a mental healthcare professional with competencies in assessment of transgender and gender diverse populations is required for individuals >18 years of age; for individuals <18 years of age, documentation must be from a mental health professional who is a member of the multidisciplinary team with competencies in assessment of transgender and gender diverse populations.

Chunk sources: [[6]]

Treatment plan and clinical notes supporting the request must be attached to the prior authorization submission.

Chunk sources: [[6]]

Form completeness: Entire prior authorization form must be completed; incomplete submissions will not be reviewed.

Chunk sources: [[6]]

Policy Summary

PayerUnitedHealthcare

PolicyGender Affirming Care (GAC) - Maryland Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Maryland GAC prior authorization form to 866-940-7328 and allow at least 24 hours for review.

SourceLink

On This Page

Prescriber attestation and monitoring: Prescriber must attest that all FDA precautions/warnings, contraindications (including Black Box Warnings) have been considered; contraindicated concurrent medications have been discontinued; height and weight will be monitored every 3 months within the first year then every 6 months thereafter; renal function, liver function, lipids, glucose, insulin, and hemoglobin A1C will be monitored within 1 year of approval (and as specified thereafter); testosterone levels will be monitored every 3 months within the first year then every 6 months thereafter; the individual will remain active in psychological and social support program; and the individual has knowledge and understanding of expected treatment outcomes.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Please complete this entire form and fax it to 866-940-7328. If you have questions, please call 800-310-6826. This form may contain multiple pages. Please complete all pages to avoid a delay in our decision. Allow at least 24 hours for review. Incomplete forms will not be reviewed and may delay the decision or result in non-review.

Fax: 866-940-7328
Phone: 800-310-6826
Allow at least 24 hours for review
Authorization duration: 12 months

Documentation Required

Required Documentation

Attach a treatment plan and relevant clinical notes to support the request. Documentation of medical necessity must be provided by a competent clinician: for individuals ≥18 years, a somatic healthcare professional (e.g., primary care) or a mental healthcare professional with competencies in assessment of transgender and gender diverse populations; for individuals <18 years, a somatic healthcare professional or a mental health professional who is part of the multidisciplinary team with those competencies. Prescriber attestation and any required laboratory results for reauthorization should also be included.

Treatment plan and clinical notes attached to support request
Documentation of medical necessity from appropriate clinician (see body)
Prescriber attestation (consideration of FDA warnings/contraindications, monitoring plans)
Laboratory results for reauthorization (testosterone levels, renal/liver function, lipids, glucose, insulin, HbA1c as specified)

Documentation Required

Prior Medication Trials Documentation

List all previous medication trials and provide the reason for failure or discontinuation for each. Complete the Previous Medication Trials section with medication name, strength, directions, dates of therapy, and reason for failure/discontinuation. This information is required to support the prior authorization decision.

Provide medication name, strength, directions, dates of therapy
Provide reason for failure or discontinuation for each prior medication trial

Background

This prior authorization form is intended to document medical necessity and required safety monitoring for medication-based gender-affirming care (for example, hormone therapies and related agents). It functions as the checklist for provider attestation, required treatment plans, clinical notes, and monitoring parameters so that the payer can evaluate initial and reauthorization requests. Providers must complete and fax the entire form to the number provided and allow at least 24 hours for review.

Definitions and Examples

Medications listed

Examples listed on formTriptodur Kit (triptorelin kit); Trelstar (triptorelin pamoate for injectable suspension); Propecia tablets (finasteride); an 'Other' option is provided for additional agents.

Triptorelin formulationsTriptodur Kit and Trelstar (triptorelin and triptorelin pamoate) are specifically named.

Finasteride examplePropecia tablets (finasteride) is listed as an example medication.

'Other' optionForm includes an 'Other' checkbox to capture additional agents not explicitly listed.

Competent clinician definition

Definition of competent clinicianFor individuals ≥18: a somatic healthcare professional (e.g., primary care) or a mental healthcare professional with competencies in assessment of transgender and gender diverse populations.

Competent clinician for minorsFor individuals <18: documentation must come from a mental health professional who is a member of the multidisciplinary team and has competencies in assessment of transgender and gender diverse populations.

Documentation requirementDocumentation of medical necessity from the competent clinician is required for authorization (initial and reauthorization).

Scope of competenciesMental health professionals must have competencies in assessment of transgender and gender diverse populations to satisfy the requirement.