CurrentUnitedHealthcarePolicy N/A

Washington Prior Authorization Request Form — Qelbree (viloxazine)

A Washington-specific prior authorization request form used by providers to request initiation or continuation of Qelbree (viloxazine) for treatment of ADHD/anti-narcolepsy for UnitedHealthcare members; applicable to prescribers submitting authorization requests and their staff.

Policy Summary

PayerUnitedHealthcare

PolicyWashington Prior Authorization Request Form — Qelbree (viloxazine)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Washington Qelbree prior authorization form by fax to 866-940-7328 and include required clinical documentation; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursreview time

866-940-7328fax

800-310-6826contact

Washingtonjurisdiction

Coverage Criteria for Qelbree (viloxazine)

Initial and Continuation Authorization Criteria

Policy Summary

PayerUnitedHealthcare

PolicyWashington Prior Authorization Request Form — Qelbree (viloxazine)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Washington Qelbree prior authorization form by fax to 866-940-7328 and include required clinical documentation; allow at least 24 hours for review.

SourceLink

On This Page

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Member and request details: Completed member information (name, ID, DOB), provider information (including NPI and specialty), medication name/strength/directions/quantity, diagnosis and ICD-10 code, pregnancy status, and hospitalization status.

From Sections A and C

Previous medication trials: List of all prior medications with strength, directions, dates of therapy, and reason for failure, intolerance, or contraindication.

Section D and Clinical and Drug Specific Information #3

Indication: Diagnosis documented as Attention Deficit Hyperactivity Disorder (ADHD) or other specified diagnosis consistent with the medication request.

Section C and Clinical and Drug Specific Information #2

Continuation therapy specific: If continuation of existing therapy, provide start date and documentation demonstrating improvement or stabilization in ADHD signs/symptoms.

Section A and Clinical and Drug Specific Information #1

Supportive documentation: Attach chart notes; include prescriber signature, prescriber specialty, and date.

Chunk 7

Submission, Documentation, and Provider Requirements

Prior Authorization

Submission and review

Submit a completed Washington Qelbree (viloxazine) prior authorization form by fax to 866-940-7328. Allow at least 24 hours for review.

Fax: 866-940-7328
Allow ≥ 24 hours for review

Step Therapy

Previous medication trials required

Provider must list all previous medication trials, including medication name, strength/directions, dates of therapy, and reason for failure, discontinuation, intolerance, or contraindication. If preferred alternatives are not appropriate, explain why in Section E and reference the patient's PDL at www.uhcprovider.com.

Include duration of use for each prior medication
Provide specific reason for discontinuation/failure or contraindication
Reference PDL at www.uhcprovider.com for preferred alternatives

Documentation Required

Required documentation

Chart notes must be submitted with the prior authorization request. The request must include the prescriber signature, prescriber specialty, and date. For continuation requests, include documentation demonstrating improvement or stabilization in ADHD signs and symptoms (for example, inattention, hyperactivity, behavior).

Required: chart notes, prescriber signature, prescriber specialty, and date
For continuations: documentation of improvement or stabilization in signs/symptoms (e.g., inattention, hyperactivity, behavior)

Denial Risk

Incomplete documentation risk

Requests submitted without the required chart notes, missing prescriber signature/specialty/date, or lacking documentation of improvement/stabilization for continuation requests may be delayed or denied.

Incomplete forms or missing documentation may delay review or result in denial
Ensure all previous medication trial details and supporting chart notes are included to avoid processing delays

Background

This Washington prior authorization form is intended to support authorization decisions for Qelbree (viloxazine) as a non-stimulant treatment option for Attention Deficit Hyperactivity Disorder (ADHD)/anti-narcolepsy. It collects member demographics and provider details, documents the requested medication (name, strength, directions, quantity) and diagnosis/ICD-10 code, and requires a record of prior medication trials (names, strengths, dates, and reasons for failure or discontinuation). Chart notes, prescriber signature, specialty, and date must be attached; for continuation requests the form requires documentation demonstrating improvement or stabilization in ADHD signs/symptoms.

Definitions and Key Fields

Continuation of Therapy — Continuation of existing therapy

DefinitionContinuation of existing therapy — request indicates therapy is ongoing and requires documentation demonstrating improvement or stabilization in signs and symptoms of ADHD (e.g., inattention, hyperactivity, behavior).

Required evidenceStart date of therapy and chart notes showing clinical improvement or stabilization must be provided for continuation requests.

Form fieldSection asks: 'Is this request for a continuation of existing therapy?' with Yes/No and follow-up documentation question.

Diagnosis / ICD-10 — Diagnosis field to include Attention Deficit Hyperactivity Disorder or other specified diagnosis and ICD-10 code

Primary diagnosisAttention Deficit Hyperactivity Disorder (ADHD).

Other diagnosis optionOther — form provides a field 'Other. Specify:' to record alternative or specified diagnoses.

ICD-10 code fieldForm includes an 'ICD-10 CODE' field to capture the applicable diagnosis code.

Form guidanceSection C requests the diagnosis be specific and to provide as much information as possible alongside the ICD-10 code.

Initial Therapy Requirements

Initial therapy

Initial request requirements

Initial request details: Indicate if request is new therapy; provide diagnosis and ICD-10 code; list prior medication trials with strength, directions, dates of therapy, and reason for failure/intolerance/contraindication; explain why preferred medications would not meet the patient's needs (refer to PDL); attach chart notes and prescriber signature.

Sections A, C, D, E and Clinical and Drug Specific Information

Continuation Therapy Requirements

Continuation therapy

Requirements for continuation requests

Continuation documentation: Indicate continuation of existing therapy and provide start date; include documentation demonstrating improvement or stabilization in signs and symptoms of ADHD (e.g., inattention, hyperactivity, behavior); attach chart notes and include prescriber signature, specialty, and date.

Clinical and Drug Specific Information #1; Chunk 7

Step Therapy / Prior Trials

Previous medication (name, strength, directions)	Dates of therapy	Reason for discontinuation / failure / intolerance / contraindication	Explanation why preferred PDL alternatives are unsuitable
Medication name, strength, directions (as listed on form)	Start and end dates of therapy (as listed on form)	Reason for failure, intolerance, discontinuation, or contraindication (as listed on form)	Provider explanation why preferred PDL medications would not meet the patient's needs (refer to patient's PDL at www.uhcprovider.com)

OpenPayer