CurrentUnitedHealthcarePolicy N/A

Washington Prior Authorization Request Form — Medical Necessity

A prior authorization request form used by UnitedHealthcare Washington to document clinical justification and supporting information for medication coverage decisions; it affects prescribers, pharmacies, and patients requesting continued or new drug therapy requiring prior authorization in Washington state.

Policy Summary

PayerUnitedHealthcare

PolicyWashington Prior Authorization Request Form — Medical Necessity

Policy CodePolicy N/A

Change TypeAdministrative — form/information update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with prescriber and pharmacy information, medication details, indication/date of diagnosis, prior therapy history, continuity-of-therapy details if applicable, and required supporting documentation; fax to 866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursturnaround

866-940-7328fax

800-310-6826phone

all diagnostic testssupporting docs

Coverage Criteria

Information and evidence required to establish medical necessity

Information requested to support medical necessity decisions (provider must supply):

Required submission elements: Completed form including patient and provider identifiers, medication name/strength/directions/quantity, diagnosis and date of diagnosis, prescriber signature and specialty, and required supporting documentation (chart notes, labs, diagnostic tests)

Provider must complete entire form to avoid delay

Continuation-specific elements: If continuation of therapy: date patient last received drug; whether continuation is based on samples or manufacturer coupons; documentation of disease stability or positive clinical benefit

Regulatory and evidence alignment: Indicate whether prescribing is in accordance with FDA labeling or supported in compendia (classified as strength of evidence category A or B and recommendation class 1 or 2a); if not, provide explanation

Policy Summary

PayerUnitedHealthcare

PolicyWashington Prior Authorization Request Form — Medical Necessity

Policy CodePolicy N/A

Change TypeAdministrative — form/information update

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Actions and Submission Requirements

Prior Authorization

Submission requirements

Submit a completed prior authorization form including prescriber and pharmacy information, medication name and strength, directions, quantity/days supply, indication and date of diagnosis, whether the request is for continuation of therapy (with last date received and source of prior therapy such as samples or coupons), and prescriber signature. Allow at least 24 hours for review.

Fax completed form to 866-940-7328
For questions call 800-310-6826

Step Therapy

Step therapy / prior treatment documentation

Indicate prior treatment history: document trials of recommended first-line therapies (per North American/WHO guidelines, FDA‑approved or compendia-supported alternatives) including each medication name, duration of trial, and outcome. If first-line therapies were not tried, provide a clear justification explaining why they were ineffective, contraindicated, or not tolerated.

List medication name, duration, and outcome for each prior trial
If No, explain why other first-line therapies were not tried

Documentation Required

Required supporting documentation

Provide complete supporting documentation with the request: current chart notes, relevant laboratory results, and all diagnostic test reports that confirm the diagnosis. For continuation requests, include documentation demonstrating disease stability or clinical benefit when applicable.

Chart notes supporting diagnosis and treatment history
Relevant labs and diagnostic test reports
Documentation of disease stability or clinical benefit for continuation requests

Denial Risk

Triggers for denial or delay

Requests may be denied or delayed if required information is missing or incomplete. Common triggers include incomplete or unsigned forms, missing prescriber/pharmacy details, absent medication details (dose, quantity, directions), lack of diagnosis date/indication, and failure to include chart notes, labs, or diagnostic test results. Also include reasons for continuation and prior-treatment justification to avoid delays.

Unsigned or incomplete prior authorization form
Missing chart notes, labs, or diagnostic test reports
Insufficient prior‑therapy documentation or missing justification for not trying first‑line treatments

Background

This document is an administrative prior authorization form intended to capture the clinical rationale and supporting evidence for medication coverage decisions, including both new starts and continuation requests. It requests patient and prescriber identifiers, medication details, diagnosis and date, confirmation of alignment with FDA labeling or compendia, documentation of prior therapies (names, durations, outcomes) or justification if not tried, and, for continuation, the date last received and documentation of disease stability or positive clinical benefit. The form requires attaching chart notes, labs and all diagnostic tests confirming the diagnosis and should be completed in full and faxed to 866-940-7328; allow at least 24 hours for review.

Definitions

Continuation of therapy

Date last receivedProvider must supply the date the patient last received the drug when the request is for continuation of therapy

Established on samples/couponsIndicate whether continuation is based on being established on samples or manufacturer coupons (Yes/No)

Clinical documentation of benefitProvide documentation demonstrating disease stability or a positive clinical benefit (Yes/No)

Complete form requirementComplete the entire prior authorization form and include continuation-specific fields to avoid delay

Compendia support

Compendia evidence categoriesForm asks whether prescribing is supported in compendia classified as strength of evidence category A or B

Recommendation classForm asks whether the condition is supported in compendia with strength of recommendation class 1 or 2a

Alignment questionProvider must indicate if the requested drug is prescribed in accordance with FDA labeling or for a condition supported in the referenced compendia (Yes/No)

If not supportedIf not aligned with compendia/FDA labeling, provider must explain why on the form

Initial Therapy Criteria

Initial therapy documentation — document indication and alignment with labeling or compendia

Initial therapy requests should document indication and alignment with labeling or compendia

Age/dose compliance: Confirm prescribed patient age, dose, and dosing frequency are within FDA labeling or supported in compendia; if not, provide justification.

Prior therapy trials: Document trials of first-line therapies recommended in North American or WHO evidence-based guidelines, FDA-approved alternatives, or compendia-supported therapies — include medication name, duration of trial, and outcome — or explain why such therapies were not tried.

Other guidelines may be used on a case-by-case basis when submitted with the request.

Required documentation	Details to include
Evidence that first-line therapies recommended by North American/WHO guidelines, FDA‑approved alternatives, or compendia‑supported therapies were tried
List each medication name, duration of trial, and outcome (ineffective, contraindicated, or not tolerated) — or provide an explanation why first‑line therapies were not tried

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