CurrentUnitedHealthcarePolicy N/A

Intron A and Sylatron – Washington Prior Authorization Request Form

This Washington-specific prior authorization request form defines submission requirements for coverage consideration of Intron A and Sylatron and applies to providers requesting prior authorization for these agents for UnitedHealthcare members in Washington.

Policy Summary

PayerUnitedHealthcare

PolicyIntron A and Sylatron – Washington Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeAdministrative/no material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the entire Washington 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.

24+listed indication/checklist items

866-940-7328fax for submission

800-310-6826phone for questions

Washingtongoverning state

Coverage Criteria & Submission Overview

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.

Information required for consideration

Coverage consideration is supported when the following are provided:

Complete form and provider/member details: All required fields in Sections A-C and provider Section B must be completed, including member demographics (name, Member ID, DOB, contact), hospitalization status if applicable, provider information (including NPI and specialty), medication details (medication name, strength, directions, quantity), ICD-10 diagnosis code, and pregnancy status.

References: chunks 1, 3

Clinical indication documented: An appropriate indication must be selected from the provided checklist (examples: chronic hepatitis B infection; myeloproliferative neoplasms such as ET, PV, PM; hairy cell leukemia; condylomata acuminata; AIDS-related Kaposi's sarcoma; leptomeningeal metastases; meningiomas; kidney cancer; follicular lymphoma; adult T-cell leukemia/lymphoma; mycosis fungoides/Sézary syndrome; desmoid tumors/aggressive fibromatosis; giant cell tumor of the bone; malignant melanoma; systemic mastocytosis).

Reference: chunk 6

Prior therapy documentation: Previous medication trials must be listed in Section D with medication name, strength, directions, dates of therapy, and reason for failure or discontinuation; Section E must explain why preferred alternatives would not meet the patient’s needs.

Reference: chunk 4

Hepatitis B-specific requirement: For requests indicating chronic hepatitis B infection, the form asks whether the patient is without decompensated liver disease and this must be documented.

Reference: chunk 7 (as indexed in brief) and chunk 6

This prior authorization form presents a checklist of eligible/covered indications for interferon alfa agents rather than listing blanket exclusions. Providers should select the specific indication that applies from the form’s checklist (for example: chronic hepatitis B, myeloproliferative neoplasms, hairy cell leukemia, condylomata acuminata, Kaposi's sarcoma, leptomeningeal metastases, meningiomas, kidney cancer, follicular lymphoma, adult T‑cell leukemia/lymphoma, mycosis fungoides/Sézary syndrome, desmoid tumors, giant cell tumor of bone, malignant melanoma, systemic mastocytosis, etc.).

Submission Instructions and Required Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Intron A and Sylatron. Complete and fax the Washington-specific Intron A and Sylatron Prior Authorization Request Form to 866-940-7328. Allow at least 24 hours for review. If you have questions, call 800-310-6826.

Complete the Washington-specific Prior Authorization Request Form
Fax completed form to 866-940-7328
Allow at least 24 hours for review
Questions: call 800-310-6826

Denial Risk

Incomplete submission / Missing clinical information

Incomplete or missing information on the form may delay the decision or result in denial. Complete all pages and fields of the Washington Prior Authorization Request Form before faxing. If clinical details requested on the form are not provided, the reviewer may request additional information which will delay the final determination.

Incomplete submissions may delay review or lead to denial
Respond promptly to requests for additional clinical information to avoid delays

Documentation Required

Required submission fields

Provide complete member and provider demographics, medication and clinical details as requested on the Washington Prior Authorization Request Form. Required fields include member name, Member ID, DOB, contact information, primary insurance (if any), whether the request is new or continuation (and start date for continuation), hospitalization status and discharge date if applicable; provider name, NPI, specialty, office contact, phone and fax; medication name, strength, directions, quantity, diagnosis and ICD-10 code; pregnancy status and due date if applicable.

Member demographics: First/Last name, Member ID, DOB, address, phone, allergies, primary insurance
Request type: New vs Continuation (if continuation, list start date)
Hospitalization status and recent discharge date if applicable
Provider information: name, NPI, specialty, address, phone, fax, office contact
Medication details: name, strength, directions, quantity
Diagnosis and ICD-10 code
Pregnancy status and due date (if applicable)

Documentation Required

Prior medication trial documentation

Document prior medication trials and clinical rationale for failure or discontinuation. On the Prior Authorization Request Form list prior medications, strength, directions, dates of therapy, and reason for failure or discontinuation. Provide an explanation why preferred alternatives would not meet the patient's needs and reference the UHC Provider Drug List (PDL) at www.uhcprovider.com when relevant.

List each prior medication, strength, directions, dates of therapy
State reason for failure or discontinuation for each prior therapy
Provide clinical rationale why preferred alternatives are unsuitable
Include any supporting clinical records as needed

Initial Therapy Requirements

Initial therapy requirements

For initial therapy requests, provide baseline patient and clinical information and prior medication history.

Initial therapy submission: Complete member information (Section A), provider information including NPI and specialty (Section B), and medical information (Section C) specifying medication name, strength, directions, quantity, ICD-10 code, and pregnancy status.

References: chunks 1, 3

Prior therapies and rationale: List all prior medication trials in Section D with medication name, strength, directions, dates of therapy, and reason for failure or discontinuation; in Section E provide an explanation why preferred medications would not meet the patient’s needs.

Reference: chunk 4

Continuation of Therapy

Continuation of therapy

The form captures whether the request is for a new start or continuation of therapy and asks for continuation start date if applicable.

Request type: Indicate whether the request is for a new start or continuation of therapy. If continuation, provide the therapy start date as requested in Section A.

Reference: chunk 1

Continuation documentation: When continuation of therapy is requested, include previous therapy details and the start date of therapy to support the request and document ongoing need.

Reference: chunk 1

Medication name	Strength / directions	Dates of therapy	Reason for failure / discontinuation	Rationale why preferred medications are unsuitable
(enter medication name)
(enter strength and directions)
(enter start and end dates)
(enter reason for failure or discontinuation)
(explain why preferred alternatives would not meet patient’s needs; see patient's PDL at www.uhcprovider.com)

Definitions and Condition Checklist

Listed indications

Chronic Hepatitis B InfectionListed as a selectable indication on the form.

Myeloproliferative Neoplasms (MPNs)Includes essential thrombocythemia (ET), polycythemia vera (PV), or primary myelofibrosis (PM).

Hairy Cell LeukemiaListed as a selectable indication on the form.

Condylomata AcuminataGenital or perianal condylomata acuminata is listed.

AIDS-Related Kaposi's SarcomaListed as a selectable indication on the form.

Malignant MelanomaListed among the oncology indications on the form.

Decompensated liver disease screening

Decompensated liver disease screening questionFor treatment of hepatitis B, the form asks: 'Is the patient without decompensated liver disease?'.

ApplicabilityThis screening question is specific to requests for treatment of hepatitis B.

DocumentationProvider signature and date are requested on the hepatitis B treatment section following the screening question.