CurrentUnitedHealthcarePolicy N/A

Colorado Uniform Pharmacy Prior Authorization Request Form

Form and instructions for requesting prior authorization of prescription drugs under the Colorado carrier/pharmacy program; used by prescribers to request new or reauthorization drug benefits for members.

Policy Summary

PayerUnitedHealthcare

PolicyColorado Uniform Pharmacy Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization form in its entirety, including patient and prescriber information, medication details, diagnosis and ICD code(s), treatment location, prior medications tried with responses, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-844-403-1027Fax number to submit form

Jan 1, 2020Opioid-dependence PA exception effective

5-dayExempt supply length

ColoradoJurisdiction

Coverage Criteria

General PA criteria

Coverage review will be based on submitted form fields and applicable statutory exceptions.

Form submission requirements: PA requests are considered when the completed form includes patient identifiers, prescriber identifiers, diagnosis and ICD code(s), drug name/strength/route/frequency/quantity/refills, start date/length of therapy, location of treatment (including name, Type 2 NPI if applicable, address and tax ID), other medications tried with duration and patient response, dispensing pharmacy information, and prescriber signature.

Form must be completed in its entirety and submitted via fax to 1-844-403-1027.

Opioid dependence exception

Statutory exception for certain substance use disorder medications

Opioid dependence PA exception: For FDA-approved prescription medications on the carrier's formulary approved to treat opioid dependence, as of January 1, 2020, no prior authorization may be imposed; if this is a first request within 12 months for prior authorization for this drug, prior authorization is not required for a 5-day supply and there may be no need to complete this form.

Policy Summary

PayerUnitedHealthcare

PolicyColorado Uniform Pharmacy Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

first request within 12 months -> 5-day supply

Provider may not need to complete or submit the form for that 5-day supply.

For FDA‑approved prescription medications on the carrier’s formulary approved to treat opioid dependence, carriers may not impose prior authorization requirements as of Jan 1, 2020. If this is a first request within 12 months for that drug, prior authorization is not required for a 5-day supply. In that circumstance there may be no need to complete the form for that 5-day supply; providers should confirm the member’s formulary status and that the request meets the first‑within‑12‑months condition before omitting form submission.

Coding

Requested Diagnosis CodesICD-10

ICD diagnostic code(s)

Patient Diagnosis and ICD Diagnostic Code(s) - free text field on form

Exempt supply length for opioid dependence medications

Exempt supply length5-day supply

ApplicabilityFirst request within a 12-month period for an FDA‑approved medication to treat opioid dependence

Effective date referencedAs of January 1, 2020

Provider Actions and Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for drug benefit requests using the Colorado Uniform Pharmacy Prior Authorization Request Form unless an exception applies (for example, a 5‑day supply of an FDA‑approved medication for opioid dependence when this is the first request within a 12‑month period). Complete the form in its entirety and submit to the carrier (fax 1-844-403-1027) with all required patient and prescriber information.

Fax submissions: 1-844-403-1027
If treating opioid dependence: first request within 12 months — a 5‑day supply does not require prior authorization
Urgent vs Non‑Urgent request indicated on form

Step Therapy

Step/Failure History Documentation

The form requests documentation of prior medications, durations, and patient responses to support step‑therapy or failure history. Provide names of other medications tried, duration of therapy for each, and the clinical response or reason for failure/intolerance.

List prior medications, start and stop dates, and clinical outcome or adverse effects
Include diagnosis and relevant ICD code(s) to justify therapy

Documentation Required

Required Documentation

Include complete patient and prescriber identifying information and clinical details to support the medical necessity of the drug. The prior authorization form must include patient name, member/subscriber number, date of birth, contact information, prescriber name, NPI, DEA, phone/fax, specialty, and signature. Also provide medication details (name, strength, route, frequency, quantity, number of refills), start date and length of therapy, location of treatment (with Type 2 NPI and tax ID if applicable), dispensing pharmacy, and any other pertinent clinical information or supporting documentation.

Required prescriber fields: name, NPI, DEA, phone, fax, tax ID, address, email, specialty/facility
Required patient fields: name, member/subscriber number, DOB, address, phone, email
Medication details: drug name (brand/scientific), strength, route, frequency, quantity, refills, dose, start date, length of therapy
Attach supporting clinical notes, test results, and documentation of prior therapy failures when applicable

Denial Risk

Denial Notification

If the prior authorization request is denied, the form will indicate the reason for denial. When denied, the provider should review the stated reason and consider alternative medications listed on the carrier formulary; include any supplemental information if appealing or resubmitting.

Denial must include reason and suggested formulary alternatives when applicable
Providers may submit additional clinical information or appeal per carrier instructions

Background

This document is the Colorado Uniform Pharmacy Prior Authorization Request Form used to collect the clinical and administrative information necessary to determine medical necessity for prescription drug coverage. Complete the form in its entirety and submit via fax to 1-844-403-1027 unless an applicable statutory exception applies.

The form explicitly implements the statutory exception effective Jan 1, 2020 that prohibits carriers from imposing prior authorization for FDA‑approved prescription medications on the formulary that treat substance use disorders. The form includes fields to indicate if the drug is intended to treat opioid dependence and whether the request is the first request within 12 months, since a qualifying first request removes the PA requirement for a 5-day supply.

Definitions

5-day supply exemption — Prior authorization exception

Exception summaryPrior authorization is not required for a 5-day supply of any FDA‑approved drug for treatment of opioid dependence for a first request within 12 months

Form completionIf the exception applies, there is no need to complete this prior authorization form for that 5-day supply

Submission method when PA requiredSubmit completed form via fax to 1-844-403-1027

Step Therapy / Failure History

Medication name	Duration tried	Patient response
Provide the name(s) of prior medication(s) tried (other medications tried).
List duration each prior medication was used (Duration).
Describe the patient response to each prior medication (Patient Response).

Quantity Limits

FDA-approved medications for opioid dependence — 5-day supply exemption noted

Covered medicationsFDA‑approved prescription medications on the carrier's formulary approved to treat opioid dependence

Quantity limit under exception5-day supply per first request within 12 months

Statutory referenceAs of January 1, 2020, carriers may not impose prior authorization for these medications under the specified condition

Site of Care Details

Note

Record site of care with name, NPI, address, tax ID

Provide the location of treatment on the form (e.g., provider office, facility, home health) and include the facility or provider name, Type 2 NPI if applicable, address and tax ID.

Specify setting (provider office, facility, home health, etc.)
Include name of location, Type 2 NPI (if applicable), address, and tax ID