CurrentUnitedHealthcarePolicy N/A

Uniform Pharmacy Prior Authorization Request Form

This document is a prior authorization (PA) request form template for pharmacy drug benefits used by UnitedHealthcare; it collects patient, prescriber, medication, clinical justification, and administrative information to request new or reauthorization drug coverage.

Policy Summary

PayerUnitedHealthcare

PolicyUniform Pharmacy Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeForm template (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and submit this form in its entirety via the online Prior Authorization and Notification Tool or by phone (number on member ID card) unless exempted (see opioid-dependence exemptions).

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is a standardized PA request form template with no listed policy changes.

1Form template for PA

1Opioid-dependence PA exemption described

Uniform Pharmacy Prior Authorization Request Form — Summary

This form is a standardized UnitedHealthcare pharmacy prior authorization (PA) request form used to initiate or renew drug benefit authorizations. It is used to collect required information to adjudicate PA requests, including patient identifiers, membership and policy details, prescriber and facility information, and administrative submission details.

The form collects patient information (name, member/subscriber number, policy/group number, date of birth, address, phone, and email), prescribing provider information (name, NPI, DEA, tax ID, specialty/facility name, address, phone, fax, pager, office contact, and email), and specifics about the requested medication (drug name with J-code if applicable, strength/route/frequency, unit/volume, start date and length of therapy, number of refills, and delivery location).

Authorization requirement for opioid dependence medications

Rules shown in the form regarding PA requirement status for FDA-approved medications for opioid dependence:

ANY of the following

As of January 1, 2020, no prior authorization requirements shall be imposed by a carrier for any FDA-approved prescription medication on its formulary which is approved to treat substance use disorders
If this is a first request within a 12-month period for this drug: authorization is not required for a 5-day supply of any FDA-approved medication for the treatment of opioid dependence and there is no need to complete this form
If 'No' (not a first request) and as of [date missing] authorization is not required for prescription medications on the carrier's formulary and there is no need to complete this form

General PA submission and documentation requirements

General PA submission requirements

Form must be completed in its entirety for PA requests except where exemptions above apply:

ALL of the following

Submit request online via Prior Authorization and Notification Tool at WWW.UHCprovider.com/lpaan or initiate by phone using number on member's ID card
Complete patient information fields (name, member/subscriber number, DOB, address, phone, email)
Complete prescribing provider information (name, NPI, DEA, tax ID, specialty/facility name, address, phone, fax, pager, office contact, email)
Indicate Urgent or Non-Urgent
Indicate whether drug is intended to treat opioid dependence (Yes/No)
Indicate whether request is New Request or Reauthorization
Provide patient diagnosis and ICD diagnostic code(s)
List drug(s) requested (with J-code if applicable), strength/route/frequency, unit/volume, start date and length of therapy, number of refills
Provide location of treatment including name, Type 2 NPI if applicable, address and ID
Provide clinical criteria for approval, including other pertinent information: other medications tried, their names, duration, and patient response
If for use in a clinical trial, provide trial name and registration number
Provide dispensing pharmacy name and phone number
Provide prescriber or authorized signature and date

Prior Authorization

Submit completed PA form

Providers must complete and submit this form in its entirety via the online Prior Authorization and Notification Tool or by phone using the number on the member's ID card unless an exemption applies (see opioid-dependence exemptions).

Online: WWW.UHCprovider.com/lpaan
Phone: number on member's ID card

Documentation Required

Clinical justification and trial history

Include the clinical criteria for approval, list other medications tried with their duration and the patient's response, provide the diagnosis with ICD diagnostic code(s), and include clinical trial name and registration number when the request is for use in a clinical trial.

Billing Rule

Provide J-code if applicable

When applicable for the requested drug (for infused or physician‑administered drugs), include the J‑code on the form to support billing.

There is a J‑Code field on the Drug(s) Requested line (include J‑Code if applicable)

Policy Summary

PayerUnitedHealthcare

PolicyUniform Pharmacy Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeForm template (no material change)

Effective Date

Next Review Date

On This Page

OpenPayer

Uniform Pharmacy Prior Authorization Request Form

Uniform Pharmacy Prior Authorization Request Form — Summary

Authorization requirement for opioid dependence medications

General PA submission and documentation requirements

Required codes for submission

Definitions

Revision history