CurrentUnitedHealthcarePolicy N/A

Prior authorization form for injectable pen products (quantity limit/medical necessity)

This document is a prior authorization form used by prescribers to request coverage for injectable pen drugs, including requests exceeding quantity limits or for non-preferred products; it affects prescribers and UnitedHealthcare adjudicators reviewing member drug benefit requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for injectable pen products (quantity limit/medical necessity)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the form with beneficiary and drug details, provide required clinical rationale for quantities over six pens per 180 days or non-preferred product exceptions, and sign the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 pensstandard maximum quantity per 180 days referenced

30/60/90/120/180/365pre-set length of therapy options

prescribersignature required

beneficiary & prescriber IDsrequired administrative data fields

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form for injectable pen products (quantity limit/medical necessity)

Policy CodePolicy N/A

Change TypeNo material changes

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.

Authorization criteria

Covered when ALL of the following are met:

administrative_fields: Beneficiary identification (name, ID, DOB, gender) and prescriber identification (NPI, contact) are provided and form is signed by prescriber.

prescriber signature mandatory

drug_info: Drug name, strength, quantity per 30 days, and length of therapy (selected from available options) are specified on the form.

length options include up to 30, 60, 90, 120, 180, 365 days or other

standard_quantity_or_exception: Requested quantity does not exceed six (6) pens per 180 days OR if it exceeds six (6) pens per 180 days, the prescriber provides medical necessity rationale in the provided field.>6 pens per 180 days requires justification

If rationale absent, request may be denied

non_preferred_criteria: If requesting a non-preferred product, prescriber documents either failure of two preferred drugs (or one if only one preferred exists) OR documents one of the following: allergic reaction, drug–drug interaction, previous unacceptable side effect or therapeutic failure, clinical contraindication/co-morbidity/unique circumstance, age-specific indication, FDA-supported unique indication (with reference), or unacceptable clinical risk with therapeutic change.

Each rationale should be described in the form fields; prescriber signature required

No explicit exclusions are listed on the prior authorization form. The form focuses on required beneficiary and prescriber identification, drug information, quantity and length of therapy, and clinical justifications for exceptions (for example, non-preferred product exceptions and quantity‑limit justifications), but does not enumerate any stated coverage exclusions on the form itself.

If the requested quantity exceeds 6 pens per 180 days, the prescriber must document medical necessity in the space provided on the form; absence of this justification may result in denial. For non‑preferred products, the prescriber must complete the required documentation of preferred‑product failure or specify an alternative acceptable rationale (e.g., allergic reaction, drug interaction, unacceptable side effect, contraindication, age‑specific indication, FDA‑supported unique indication, or unacceptable clinical risk) and also provide a quantity‑limit justification when requesting more than 6 pens per 180 days. The form requires the prescriber’s signature and date, and missing signature or missing justification fields can lead to denial of the request.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for requests exceeding approved quantity limits or for non-preferred products. Providers must document justification when requesting > 6 pens per 180 days; failure to provide sufficient justification may result in denial or delay.

Quantity limit threshold: > 6 pens per 180 days
Applicable to both preferred and non-preferred products

Documentation Required

Quantity Limit Justification Required

If requesting quantities that exceed the standard limit (more than six pens per 180 days), the prescriber must provide a clear medical justification describing why the standard limit is insufficient for this patient. Examples include dosing requirements based on weight, documented increased therapeutic need, or other clinically significant reasons.

State the exact quantity requested and the time period (e.g., 8 pens per 180 days)
Provide clinical rationale and any supporting objective data (e.g., recent weight, labs, treatment response)

Documentation Required

Required Form Fields and Supporting Clinical Documentation

Complete all required form fields and attach supporting clinical documentation. Required fields include beneficiary identifiers, prescriber identifiers, and full drug details.

Beneficiary: Last name, First name, Beneficiary ID#, Date of Birth, Gender
Prescriber: Prescribing Provider NPI#, Requester contact name and phone (with ext.)
Drug: Drug name, Strength, Quantity per 30 days, Length of therapy (select duration)
Signature: Prescriber signature and date (mandatory)
Attach: Relevant clinical notes, prior medication trials, lab results, and any supporting literature or FDA documentation

Step Therapy

Preferred Product Failure Requirements

For non-preferred product requests, documentation must show failure of preferred products per step-therapy rules: provide evidence of trial and inadequate response or intolerance.

Document failure of two preferred drugs (or one, if only one preferred product exists) with dates and reasons for discontinuation
Specify reason: allergic reaction, drug–drug interaction (describe), unacceptable side effect or therapeutic failure (provide clinical details), clinical contraindication/co-morbidity, age-specific indication (state age), unique FDA-supported indication or peer-reviewed literature reference, or unacceptable clinical risk with therapeutic change
Include prior authorization history or medication fill records when available

Step Therapy / Supporting Documentation

Documentation Required on Form	Notes / Required Details
Failed preferred product documentation (non-preferred products)
Check box for 'Failed two preferred drug(s)' (or 'one' if only one preferred exists); list preferred drugs failed and provide supporting details.
Clinical reason codes (select as applicable)
Options include: Allergic reaction; Drug-to-drug interaction (describe reaction); Previous unacceptable side effect or therapeutic failure (provide clinical info); Clinical contraindication/co-morbidity or unique patient circumstance (provide clinical info).
Age-specific indication
Provide patient age and explanation for age-specific indication.
FDA-supported or literature-supported unique clinical indication
Explain indication and provide a general reference (FDA approval or peer-reviewed literature).
Unacceptable clinical risk with therapeutic change
Explain why therapeutic change poses unacceptable clinical risk.
Quantity limit question
Is the requested quantity for more than 6 pens per 180 days? Check Yes or No.
Quantity limit medical necessity rationale (required if >6 pens/180 days)
Prescriber must submit reasoning for medical necessity of quantities exceeding the allowable maximum of six (6) pens per 180 days; provide clinical justification in the space provided.
Prescriber signature and date
Prescriber signature is mandatory; certifies accuracy of information (signature line and date required).

Quantity Limits Summary

Injectable pen products — quantity

Standard quantity limit6 pens per 180 days

Required documentation for non-preferred productsDocumentation of failure of two preferred drugs (or one if only one preferred exists) or other documented clinical rationale (allergy, interaction, unacceptable side effect, contraindication, age-specific indication, FDA-supported unique indication)

Form fields to completeIndicate if requested quantity exceeds 6 pens per 180 days and provide prescriber reasoning in the provided field

Signature requirementPrescriber signature and date required on form

OpenPayer

Prior authorization form for injectable pen products (quantity limit/medical necessity)

Coverage Criteria

Coding & Quantity Limits

Provider Actions and Documentation Requirements

Step Therapy / Supporting Documentation

Quantity Limits Summary