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.
No material clinical/coverage changes — this is a standardized PA request form template with no listed policy changes.
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).
It also captures clinical justification required for approval, including patient diagnosis and ICD diagnostic code(s), treatment history and response to other medications, whether the request is a New Request or Reauthorization, whether the drug is intended to treat opioid dependence, clinical trial details if applicable, dispensing pharmacy, and prescriber or authorized signature and date.
Authorization requirement for opioid dependence medications
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
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