CurrentUnitedHealthcarePolicy N/A

Provider-administered drug prior authorization form (opioid-specific sections)

This document is a UnitedHealthcare prior authorization request form for prescription and provider-administered medications, with dedicated sections for opioid-specific attestations; it governs information providers must submit to request authorization for member drug therapy.

Policy Summary

PayerUnitedHealthcare

PolicyProvider-administered drug prior authorization form (opioid-specific sections)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvider must supply HCPCS/CPT-4 or NDC for provider-administered drugs, ICD-10 diagnosis codes, pertinent labs, prior treatment history, and complete opioid attestations A-L when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections I-VIIform sections included

A-Lopioid attestation points

HCPCS/NDCcoding captured

PresentMME fields

Opioid and Drug Coverage Criteria

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Opioid Prescriber Attestations

Provider must attest to ALL of the following for long-acting opioid requests

Opioid attestations A-L: A. A complete assessment for pain and function was performed for this patient.; B. The patient has been screened for substance abuse/opioid dependence (not required for recipients in long-term care facility).; C. The Prescription Monitoring Program (PMP) will be accessed each time a controlled prescription is written for this patient.; D. A treatment plan including current and previous goals of therapy for pain and function has been developed.; E. Criteria for failure of the opioid trial and for stopping or continuing the opioid have been established and explained to the patient.; F. Benefits and potential harms of opioid use have been discussed with the patient.; G. An Opioid Treatment Agreement signed by both patient and prescriber is on file (not required for recipients in long-term care facility).; H. The patient requires continuous, around-the-clock analgesic therapy for which alternative treatments have been inadequate or not tolerated.; I. Patient previously utilized at least two weeks of short-acting opioids for this condition (provider must enter drug(s), dose, duration and date of trial in the pharmacologic/non-pharmacologic treatment section).; J. Medication has not been prescribed to treat acute pain, mild pain, or pain not expected to persist for an extended period of time.; K. Medication has not been prescribed for use as an as-needed (PRN) analgesic.; L. Prescribing information for the requested product has been thoroughly reviewed by the prescriber.

If any attestation (A-L) is not met, the prescriber must provide an explanation.

Opioids prescribed for acute pain, mild pain, pain not expected to persist for an extended period, or for as‑needed (PRN) use are not consistent with the attestation requirements for long‑acting opioid authorization. The prescriber must complete the opioid attestation section (A–L) confirming the assessment, screening, treatment plan, prior short‑acting opioid trial, and safeguards such as an opioid treatment agreement where applicable; if any attestation (A–L) is not met the prescriber must provide an explanation on the form.

Requests will be considered not medically necessary and may be denied when required opioid attestations (A–L) are missing or not completed, when documentation of a prior trial of at least two weeks of short‑acting opioids for the condition is not provided, or when the request indicates the patient’s cumulative daily MME exceeds the permitted maximum without an explanatory justification documented on the form.

The prescriber must report the cumulative daily MME and indicate whether it exceeds the daily maximum allowed; if the quantity requested exceeds the max quantity limit or the cumulative daily MME exceeds the allowed maximum, a justification must be provided in the space on the form or the request may be denied or delayed.

What the Provider Must Submit

Prior Authorization

Prior Authorization Submission Requirements

Prior authorization (PA) must include complete prescription drug information. Provide the requested drug name, strength, dosage form, route of administration, quantity, days' supply, dosage interval/directions for use, expected therapy duration or start date, and indicate whether this is a new/initial request or a continuation/reauthorization.

Requested Drug Name, Strength, Dosage Form, Route of Admin, Quantity, Days' Supply, Dosage Interval/Directions for Use, Expected Therapy Duration/Start Date
Indicate: New therapy/Initial request OR Continuation of therapy/Reauthorization request

Documentation Required

Provider‑Administered Drug Information Required

For provider‑administered drugs include billing and product identifiers: HCPCS/CPT‑4 code(s), NDC number(s), dose per administration, and any other applicable codes. State whether the patient will receive the drug in the physician’s office; if not, provide the name and NPI of the servicing provider or facility.

HCPCS/CPT-4 Code(s)
NDC# and Dose Per Administration
Other applicable codes
Specify site of administration; if not in prescriber’s office, provide servicing provider/facility name and NPI

Documentation Required

Required Clinical Documentation for PA

Document clinical information that supports medical necessity for the requested drug: primary and secondary ICD‑10 diagnosis codes with dates diagnosed, pertinent laboratory values with dates, and relevant clinical records. Include prior and current pharmacologic and non‑pharmacologic treatments (drug name, strength, frequency, dates/duration, response, and reason for discontinuation) and any drug allergies, height/weight if applicable.

Primary and secondary diagnosis and ICD‑10 codes with dates
Pertinent laboratory values and dates (attach results)
Pharmacologic & non‑pharmacologic treatments used (drug, strength, frequency, dates/duration, response)
Drug allergies; height and weight if applicable

Step Therapy

Step Therapy Declaration

Step therapy: indicate whether the patient has used the plan’s prerequisite (step) medication(s). If previous or concurrent use of required step therapy medications is not present, provide a clear clinical explanation why the prerequisite medication(s) are expected to be ineffective or would cause an adverse reaction.

State prior/concurrent use of prerequisite medications or select: patient did not tolerate/has contraindication/expected ineffective — provide explanation in clinical section

Denial Risk

Incomplete Drug Information May Delay Review

Incomplete or missing drug information may render the PA request incomplete and delay adjudication. Missing required elements include drug name, strength, dosage, quantity, days' supply, dose per administration (for provider‑administered), HCPCS/CPT‑4 or NDC, and expected therapy duration. Ensure all fields are completed before submission.

Ensure drug name, strength, dosage, quantity, days' supply, and expected therapy duration are provided
For provider‑administered drugs include HCPCS/CPT‑4, NDC, and dose per administration

Initial Therapy Requests

Initial Therapy

Initial therapy requests

Initial request fields: For new therapy, provider must indicate 'New therapy/Initial request' and provide pharmacologic and non-pharmacologic treatment history (drug name, strength, frequency, dates started and stopped or approximate duration, and response/reason), drug allergies, height/weight if applicable, and rationale if plan prerequisite (step) medications are expected to be ineffective or cause an adverse reaction.

If the provider indicates step medications will be ineffective or cause an adverse reaction, an explanation must be provided in Section VIII.

Question	Provider response required	If yes, where to explain
Is there clinical evidence or patient history that suggests the use of the plan's pre-requisite medication(s), e.g. step medications, will be ineffective or cause an adverse reaction to the patient?	Provider must indicate Yes or No on the form	If Yes, provider must explain in Section VIII

Key Definitions

inv-12: PMP access

PMP access requirementPrescription Monitoring Program (PMP) will be accessed each time a controlled prescription is written for this patient.

ApplicabilityApplies to controlled prescriptions documented in the opioid-specific prescriber attestations section (Section VI).

Attestation contextPrescriber attests to PMP access as one of the required opioid attestations (item C).

inv-13: Cumulative daily MME definition

DefinitionCumulative daily Morphine Milligram Equivalent (MME) — provider must report the calculated cumulative daily MME amount for the patient.

Exceedance questionForm asks: Does cumulative daily MME exceed the daily max MME allowed? (Yes/No) — provider must indicate response.

If yes actionIf the cumulative daily MME exceeds the allowed maximum, the provider must provide a justification on the form.

Policy Background and Scope

This authorization form is used to request coverage for both prescription and provider‑administered medications and captures patient identifiers, diagnosis codes, and clinical data required to evaluate therapy. For opioid requests the form includes a dedicated opioid section where the prescriber attests to safety and treatment elements (A–L) and documents prior treatment history, including short‑acting opioid trials.

Providers must complete the prescription drug information section for prior authorization; for provider‑administered drugs the form captures procedure/administration codes (e.g., HCPCS/CPT‑4) and/or NDC, dose per administration, and site‑of‑care details. The form also requests primary and secondary ICD‑10 diagnosis codes and pertinent clinical information such as prior pharmacologic and non‑pharmacologic treatments and relevant laboratory values.

By signing the form the prescriber attests that the information provided is true and accurate and that they have completed the attestations specific to the request (including opioid attestations where applicable); incomplete drug or prescriber information, missing codes, or absent attestations may result in denial or delay of the prior authorization.

OpenPayer

Provider-administered drug prior authorization form (opioid-specific sections)

Opioid and Drug Coverage Criteria

Drug and Diagnosis Coding

What the Provider Must Submit

Initial Therapy Requests

Continuation / Reauthorization Requests

Step Therapy and Prerequisite Medications

Site of Care and Servicing Provider

Key Definitions

Policy Background and Scope

HCPCS/CPT-4	Field for provider-administered drug procedure/code
NDC	Field for National Drug Code for administered drug