CurrentUnitedHealthcarePolicy N/A

Specialty Medication Prior Authorization Cover Sheet

Forms and instructions to accompany pharmacy prior authorization requests for specialty medications; intended for providers and specialty pharmacies submitting prior authorization documentation to UnitedHealthcare in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicySpecialty Medication Prior Authorization Cover Sheet

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form by fax 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.

24form fields/pages and checklist sections (approx.)

866-940-7328fax number for prior authorization submission

800-310-6826phone for questions

Lenvimaexample drug-specific PA section included

Coverage Criteria

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Lenvima - All Requests: Requested use is for a diagnosis supported by the NCCN Drugs and Biologics Compendium (provider must indicate if yes and list the supported use).NCCN-supported use

From Clinical and Drug Specific Information section

Thyroid cancer criteria: Patient has unresectable or locally recurrent disease OR metastatic disease OR persistent locoregional disease; disease is symptomatic or progressive; disease is refractory to radioactive iodine; and patient has history of failure, contraindication, or intolerance to vandetanib (Caprelsa) or cabozantinib (Cometriq) when applicable (complete Section D for prior therapy details).checkbox items

From THYROID CANCER section

Renal cell cancer criteria: Patient has advanced renal cell cancer with history of failure, contraindication, or intolerance to prior anti-angiogenic therapy (e.g., bevacizumab, pazopanib, sunitinib, sorafenib); document prior therapies in Section D and indicate if Lenvima will be used in combination with everolimus (Afinitor).checkbox items

From RENAL CELL CANCER section

Continuation of therapy: For continuation requests, provider must indicate whether there is evidence of progressive disease on Lenvima therapy and whether there is a documented positive clinical response to therapy; physician signature and dates required on the form.checkboxes and signature

From CONTINUATION OF THERAPY section

The prior authorization cover sheet requires providers to indicate whether the requested use is supported by the NCCN Drugs and Biologics Compendium. Requests for indications that are not NCCN-supported should be clearly identified on the form; absence of an NCCN-supported indication may affect coverage unless a documented exception is provided. Providers should list the NCCN-supported use when applicable.

For many disease-specific indications the form requires documentation of prior therapy trials and particular disease characteristics. Examples: for thyroid cancer the patient must have unresectable, locally recurrent, persistent locoregional, or metastatic disease that is symptomatic or progressive and refractory to radioactive iodine, and the form asks whether there is a history of failure/contraindication/intolerance to vandetanib or cabozantinib. For renal cell cancer the form asks whether the patient has a history of failure/contraindication/intolerance to prior anti‑angiogenic therapy (examples listed) and whether Lenvima will be used in combination with everolimus. Requests that do not document the required prior therapy trials or that describe disease states not meeting the listed criteria (for example, non‑progressive or resectable disease where progression/unresectability is required) may not meet medical necessity.

Coding

Requested diagnosis codesICD-10

ICD-10

ICD10 Code / ICD-10 CODE (field on form; specific code to be entered by provider)

Documentation of positive clinical response

Documentation of positive clinical responseIs there documentation of positive clinical response to current therapy? — Yes / No checkbox on the form

Physician attestationPhysician signature required on medication information section to validate clinical response and dispense coordination

Attach supporting recordsAttach any pertinent clinical information that supports the stated diagnosis and documented response

Provider Submission & Actions

Prior Authorization

Submission Instructions

Please complete the entire prior authorization form and submit all required attachments. Incomplete submissions (missing pages, missing clinical attachments, or missing prior medication trial documentation) may delay processing or result in denial. Allow at least 24 hours for review after a complete submission.

Fax completed form and attachments to: 866-940-7328
Questions? Call: 800-310-6826
Allow at least 24 hours for review after a complete submission

Documentation Required

Document Prior Medication Trials & Continuation Details

Document previous medication trials and reasons for failure or discontinuation for the requested therapy. For continuation requests, include initiation date, date of last dose, and documentation of positive clinical response. Attach clinical notes or chart documentation supporting the stated diagnosis and response to therapy.

Attach prior medication trials: drug name, strength, directions, dates of therapy, and reason for failure/discontinuation
For continuation requests, include initiation date and date of last dose and evidence of clinical benefit
Include any additional clinical information required by the member's plan (e.g., prior therapies tried and failed)

Documentation Required

Required Clinical Attachments

Attach all required clinical documentation to support the request, including the prior medications table, relevant labs, imaging, pathology, and clinician notes that demonstrate medical necessity. Failure to attach pertinent clinical information may result in an incomplete submission and delay.

Attach completed Medication Instructions section if continuation: initiation date, date of last dose, and evidence of response
Attach medical records that justify why preferred alternatives would not meet the patient's needs (see PDL at www.uhcprovider.com)

Denial Risk

Incomplete Submission Risk

Incomplete forms or missing attachments increase the risk of delayed decisions or denials. Ensure all sections (Member Information, Medical Information, Previous Medication Trials, and Clinical/Drug-Specific Information) are fully completed and all supporting documents are attached before faxing.

Incomplete submissions may delay the decision — double-check all pages are completed
If continuation of therapy, confirm documentation of positive clinical response is attached
Allow at least 24 hours for review after a complete submission

Background

This cover sheet and associated prior authorization request form collect the clinical and drug‑specific information needed to evaluate specialty medication requests. The Lenvima section illustrates required fields: diagnosis checkboxes, confirmation of whether the requested use is NCCN‑supported, disease‑specific criteria (for example, unresectable/metastatic and progressive disease for thyroid cancer), and questions about prior therapy failures or contraindications. Completing these items helps ensure the reviewer can determine whether the request meets the listed initial or continuation criteria.

Definitions

Continuation of Therapy — documentation and form fields

Continuation indicatorForm includes the question 'Is this medication a New Start? — Yes / No' and asks for completion of continuation details when 'No' is selected

Initiation dateContinuation requests must provide Initiation Date (MM/DD/YYYY) as requested in the Medication Instructions section

Date of last doseContinuation requests must provide Date of Last Dose (MM/DD/YYYY) as requested in the Medication Instructions section

Required attachmentsPlease attach pertinent clinical information (including prior medications tried/failed and documentation of clinical response) to support continuation

Physician signature for dispensing/deliveryPhysician Signature on the Medication Information section authorizes the specialty pharmacy to dispense and coordinate delivery for the ongoing medication

Initial Therapy

Initial request considerations for Lenvima

Initial Lenvima request: Document the diagnosis selected from the provided list (e.g., follicular, Hürthle cell, papillary, medullary thyroid carcinoma; advanced renal cell cancer; hepatocellular carcinoma) and indicate if the requested use is supported by the NCCN Drugs and Biologics Compendium (list supported use if yes).checkboxes and prior therapy documentation

From Clinical and Drug Specific Information section

Disease characteristics: Indicate disease status as applicable (e.g., unresectable or locally recurrent, metastatic, persistent locoregional) and whether disease is symptomatic or progressive and refractory to radioactive iodine when applicable (thyroid cancer criteria).checkboxes

From THYROID CANCER section

Prior therapy documentation: Provide prior medication trial history and reasons for failure or intolerance; for thyroid cancer document prior vandetanib (Caprelsa) or cabozantinib (Cometriq) failure/contraindication/intolerance when applicable; for renal cell cancer document prior anti-angiogenic therapy failure/contraindication/intolerance (examples listed).complete Section D with dates and reasons

From THYROID CANCER and RENAL CELL CANCER sections

Continuation of Therapy

Requirements for continuation requests

Continuation requirements: Indicate that the request is for continuation of therapy and provide initiation date and date of last dose; document whether there is progressive disease while on Lenvima and whether there is a documented positive clinical response to therapy; physician signature required.checkboxes and dates

From CONTINUATION OF THERAPY and Medication Instructions sections

Step Therapy / Prior Trials

Medication	Dates of Therapy	Reason for failure / discontinuation
Caprelsa (vandetanib)	(enter dates)	History of failure, contraindication, or intolerance (complete Section D)
Cometriq (cabozantinib)	(enter dates)	History of failure, contraindication, or intolerance (complete Section D)
Prior anti-angiogenic therapy (e.g., bevacizumab, pazopanib, sunitinib, sorafenib)	(enter dates)	History of failure, contraindication, or intolerance (complete Section D)
Other prior medication(s)	(enter dates)	Reason for failure / discontinuation (document in Section D)

Site of Care / Shipping

Note

Choose ship-to and site-of-care options

Select the ship-to location and medication administration setting on the delivery instructions: options include physician’s office or patient’s address for shipment, and administration settings include self-administered at home, long‑term care, physician’s office, or home health.

Ship-to options: Physician's Office or Patient's Address (provide date medication is needed).
Administration setting options: Self‑Administered (home), LTC, Physician's Office, or Home Health.