CurrentUnitedHealthcarePolicy N/A

ASAP: Adult Safety with Antipsychotic Prescribing [18 Years of Age and Older] (North Carolina) Prior Authorization Form - Community Planopen_in_new

A prescriber-completed prior authorization (PA) form to request coverage for antipsychotic medications for beneficiaries aged 18 and older in UnitedHealthcare Community Plan North Carolina, documenting beneficiary, prescriber, drug, clinical rationale, contraindications, and informed-consent elements for a 365-day authorization.

Policy Summary

PayerUnitedHealthcare

PolicyASAP: Adult Safety with Antipsychotic Prescribing [18 Years of Age and Older] (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the form including beneficiary, prescriber, drug, clinical diagnosis, target symptom, informed-consent responses, and rationale for non-preferred medication if applicable to request a 365-day prior authorization for antipsychotic medications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted.

1Form Required Signature

365Authorization Length (days)

Policy overview

This is a UnitedHealthcare Community Plan North Carolina prescriber-completed prior authorization form used under the ASAP program to document clinical rationale and informed consent for adult antipsychotic prescribing (beneficiaries aged 18+). The form captures beneficiary identifiers (name, ID, DOB, gender), prescriber details (including NPI and contact), and drug information (name, strength, quantity per 30 days, and Length of Therapy: 365 days). It requires documentation of clinical diagnosis and target symptoms, justification for use of a non-preferred medication when applicable (including failed preferred drug, allergy, drug–drug interaction, prior unacceptable side effects or therapeutic failure, contraindication/co-morbidity, age-specific indication, FDA/literature-supported indication, or unacceptable clinical risk), informed-consent responses about metabolic and neurologic adverse effects, and a mandatory prescriber signature and attestation.

Form completion and provider requirements

Prior Authorization

Complete PA Form for Antipsychotic Therapy

Prescriber must complete and sign the form including beneficiary, prescriber, drug, clinical diagnosis, target symptom, informed-consent responses, and rationale for non-preferred medication if applicable to request a 365-day prior authorization for antipsychotic medications.

Beneficiary: last name, first name, beneficiary ID, date of birth, gender
Prescriber: prescribing provider NPI, provider fax, requester contact name and phone
Drug: drug name, strength, quantity per 30 days, length of therapy (365 days)
Clinical diagnosis: primary psychiatric diagnosis (select from list or specify Other)
Target symptom: select target symptom (or specify Other)
Informed-consent: metabolic and neurologic risk discussions recorded (Yes/No)
Rationale for non-preferred drug: provide justification if applicable
Prescriber signature and date

Documentation Required

Document failure/contraindication to preferred drugs when requesting non-preferred medications

If requesting a non-preferred medication, provide documentation selecting at least one justification from the form and include accompanying clinical details as indicated.

Failed 1 preferred drug — list preferred drugs failed
Allergic reaction
Drug–drug interaction — describe the interaction/reaction
Previous unacceptable side effect or therapeutic failure — provide clinical information
Clinical contraindication, co-morbidity, or unique patient circumstance — explain and provide clinical information
Age-specific indication — give patient age and explain
Unique clinical indication supported by FDA approval or peer‑reviewed literature — explain and provide reference
Unacceptable clinical risk associated with therapeutic change — explain

Documentation Required

Obtain informed consent discussion documentation

Document that the patient/guardian was informed of metabolic and neurologic adverse effects and that they wish to continue therapy; record Yes/No responses on the form.

Record Yes or No for "informed of potential metabolic adverse effects and wishes to continue"
Record Yes or No for "informed of potential neurologic adverse effects and wishes to continue"

Documentation Required

Obtain prescriber signature

Prescriber signature is mandatory and certifies accuracy; the form is invalid without the prescriber signature and date.

Prescriber must sign and date the form
Signature certifies accuracy and acknowledges legal liability for falsification

Definitions

Non-preferred medicationA medication not listed as preferred by the plan that requires additional justification for PA (e.g., failed preferred drug, contraindication, or other listed reasons).

Purpose: The form documents the clinical rationale and informed consent for adult antipsychotic prescribing under the ASAP program. It captures required prescriber and beneficiary data, the beneficiary's primary psychiatric diagnosis and target symptom(s), reasons for requesting a non-preferred medication (with selectable justifications and clinical details), and an attestation that the patient/guardian has been counseled about and informed of potential metabolic and neurologic risks and wishes to continue therapy. The prescriber must sign and date the form certifying accuracy.

Who and when this form applies

Scope: This prescriber-completed prior authorization form is for beneficiaries aged 18 and older in UnitedHealthcare Community Plan North Carolina and is required to request a 365-day prior authorization for antipsychotic medications. The prescriber must complete and sign the form and document beneficiary identification, prescriber information, drug name/strength/quantity and length of therapy, the primary psychiatric diagnosis and target symptom(s), responses to informed-consent questions about metabolic and neurologic adverse effects (Yes/No), and, if requesting a non-preferred medication, provide at least one justification with supporting clinical information.

Compact summary

RegionNorth Carolina

PopulationAdults 18+

Authorization length365 days

Form required signatureYes

Policy Summary

PayerUnitedHealthcare

PolicyASAP: Adult Safety with Antipsychotic Prescribing [18 Years of Age and Older] (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

ASAP: Adult Safety with Antipsychotic Prescribing [18 Years of Age and Older] (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy overview

Form completion and provider requirements

Form-level required documentation / criteria

Definitions

Who and when this form applies

Document changes