CurrentUnitedHealthcarePolicy N/A

Antipsychotics - Pennsylvania Prior Authorization Request Form

A Pennsylvania-specific prior authorization request form for antipsychotic medications used by UnitedHealthcare; it documents required prescriber, clinical, medication, monitoring, and prior trial information to obtain authorization.

Policy Summary

PayerUnitedHealthcare

PolicyAntipsychotics - Pennsylvania Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Pennsylvania antipsychotic prior authorization form to UnitedHealthcare and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24hminimum review turnaround

866-940-7328submission fax

800-310-6826provider questions

includedpediatric monitoring

Coverage Criteria

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All requests: Form fully completed and submitted including prescriber and patient identifiers; diagnosis and ICD-10 code provided

Fax prior authorization form to UnitedHealthcare; allow at least 24 hours for decision (see contact/fax on form)

Prior therapy: Patient has history of therapeutic failure, contraindication, or intolerance to preferred antipsychotics OR documentation justifying use of non-preferred agent; the Previous Medication Trials/Contraindications section is complete with medications tried, strengths, directions, length of trial, and reasons for discontinuation

Refer to the patient PDL at www.uhcprovider.com

Current therapy check: Documentation if the patient has been prescribed the same requested medication within the past 90 days

If yes, complete relevant medication history fields

Pediatric-specific: If patient is <18 years, a comprehensive evaluation including non-pharmacologic therapies is documented and baseline and ongoing metabolic and extrapyramidal symptom (EPS) monitoring is provided

Monitoring includes weight/BMI, blood pressure, fasting glucose, fasting lipid panel, and AIMS; continuation requires documented improvement and periodic monitoring

For requests involving INVEGA (paliperidone ER), the form specifically asks whether the patient has active liver disease with elevated liver function tests (LFTs) or is otherwise at risk for active liver disease. This information must be identified on the prior authorization form so the reviewer can consider hepatic status when assessing safety and appropriateness for paliperidone ER.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

All antipsychotic requests for Pennsylvania members require prior authorization. Complete and fax the Antipsychotics - Pennsylvania Prior Authorization Request Form to 866-940-7328. Allow at least 24 hours for review. For questions, call 800-310-6826.

Complete entire prior authorization form — incomplete forms may delay decision
Notify if request is new or continuation of therapy; if continuation, include therapy start date
Indicate if patient is currently hospitalized or recently discharged and provide discharge date

Documentation Required

Required Clinical & Administrative Documentation

Prescriber must provide complete clinical and administrative documentation on the form: prescriber/member identification (member name, member ID, DOB, provider name, NPI, specialty, office and fax numbers, address), ICD-10 diagnosis code(s), and any supporting laboratory or test results related to the diagnosis.

Include allergies and pregnancy status (and due date if pregnant)
Provide documentation of supporting labs/tests where applicable
Indicate whether request is new or continuation and prior authorization start date if continuation

Documentation Required

Pediatric Monitoring & Specialist Involvement (Patients <18)

For patients under 18 years, include documentation of: comprehensive evaluation and evidence of non-pharmacologic therapies (behavioral, cognitive, family-based therapies, etc.), prescribing or consult by an appropriate specialist (child/adolescent psychiatrist, general psychiatrist, child development pediatrician, pediatric neurologist), and baseline monitoring.

Document severe behavioral problems related to relevant diagnoses (autism spectrum disorder, bipolar disease, conduct disorder, intellectual disability, schizophrenia, tic disorder, transient encephalopathy) when applicable
Provide baseline monitoring of weight/BMI, blood pressure, fasting glucose, fasting lipid panel, and EPS using AIMS
For continuation: document improvement in target symptoms, quarterly weight/BMI monitoring, and BP/glucose/lipids/EPS monitoring after 3 months and then annually, plus a taper/discontinuation plan or rationale for continued use

Note

Preferred-Agent Trial / PDL Reference

Document trials of preferred agents or reasons they are unsuitable. Refer to the UnitedHealthcare Provider Drug List (PDL) for preferred antipsychotics and list all prior medication trials, including strengths, directions, length of trial, and reason for discontinuation, or document specific contraindications/intolerances.

If patient has therapeutic failure, contraindication, or intolerance to preferred antipsychotics, complete the "Previous Medication Trials/Contraindications" section on the form
Provide exact names, doses, durations, and reasons (failure, intolerance, contraindication) for all prior medications

Background

Antipsychotic medications are prescribed across age groups for psychotic disorders and certain neurodevelopmental conditions. For patients <18 years, the form requires documentation of a comprehensive evaluation, including non-pharmacologic therapies and details supporting the need for an antipsychotic, because pediatric prescribing carries additional safety considerations.

Pediatric-specific monitoring must be documented for initiation and continuation of therapy. The form requests baseline and ongoing assessments of metabolic parameters and extrapyramidal symptoms — including weight/BMI, blood pressure, fasting glucose, fasting lipid panel, and an AIMS exam — and continuation requests require evidence of clinical improvement and a monitoring plan.

When completing a prior authorization for a patient under 18, include the clinical rationale, documentation of prior non-pharmacologic interventions where applicable, and the scheduled metabolic/EPS monitoring results to support safe, ongoing treatment.

Definitions / Concomitant Use

Therapeutic duplication / concomitant use — documentation when titrating or tapering from another antipsychotic and required justification

When this appliesDocument if the patient is being titrated to or tapered from another antipsychotic (atypical or typical).

Required justificationPrescriber must state a medical reason for concomitant or transition use supported by peer‑reviewed literature or national treatment guidelines.

Documentation elementProvider signature and date certifying the rationale for therapeutic duplication/concomitant use on the form.

ScopeApplies separately for atypical and typical antipsychotics (questions ask about titration/taper for each class).

Related pediatric considerationIf patient is <18 years, ensure comprehensive evaluation and baseline/ongoing monitoring (weight/BMI, BP, fasting glucose, fasting lipid panel, AIMS) are documented in addition to rationale for duplication/concomitant use.