CurrentUnitedHealthcarePolicy N/A

Prior Authorization Form for Non‑Preferred Psychiatric Medications — Coverage Criteria

Form documenting beneficiary, prescriber, drug, and clinical rationale required for prior authorization of non-preferred psychiatric medications for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Form for Non‑Preferred Psychiatric Medications — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization form with beneficiary and prescriber details, drug information, non-preferred justification, informed consent documentation, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365Default length of therapy

11 fieldsMain form sections

multipleBehavioral health options

Coverage Criteria

Authorization criteria

Covered when ALL of the following are met and documented on the form:

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Form for Non‑Preferred Psychiatric Medications — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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If the provider does not document either a trial-and-failure of preferred therapy or at least one other acceptable justification for use of a non-preferred medication (for example: allergy, drug–drug interaction, previous unacceptable side effect or therapeutic failure, clinical contraindication/comorbidity, age-specific indication, FDA-supported unique indication, or unacceptable clinical risk), the request may not meet the form’s requirements and may result in denial. The form specifically asks whether a preferred drug was failed and requests listing of preferred drugs failed or selection of one or more alternative justifications with supporting clinical details.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Form Completion

Prior authorization form completion is required for requests of non-preferred medications. Complete the full prior authorization form including beneficiary identifiers, prescriber contact/NPI, drug name, strength, quantity, and length of therapy. Ensure the prescriber signature and date are included.

Include beneficiary name, beneficiary ID number, date of birth, and gender.
Provide prescribing provider NPI, provider fax, and requester contact name and phone number (with ext. if applicable).
Document drug name, strength, quantity per 30 days, and length of therapy (e.g., 365 days if applicable).
Prescriber signature and date are mandatory.

Step Therapy

Step Therapy / Failed Preferred Drug

When requesting a non-preferred medication, document step therapy information. Indicate whether the patient failed one or more preferred drugs and list the specific preferred agents tried and dates of trial. Failure, intolerance, or contraindication to preferred drugs must be clearly documented.

Check and mark whether the patient has failed 1 (or more) preferred drug(s).
List each preferred drug tried and the reason for failure (e.g., lack of efficacy, allergic reaction, drug–drug interaction, unacceptable side effect).
If no preferred drug was tried, provide clinical justification for bypassing step therapy (see documentation requirements).

Documentation Required

Required Documentation

Required documentation must accompany the prior authorization request. Incomplete or missing documentation may result in denial or delay. Provide clear clinical rationale for use of the non-preferred agent tied to the patient’s diagnosis and target symptoms.

Beneficiary identifiers: last name, first name, beneficiary ID #, date of birth, gender.
Prescriber information: prescribing provider NPI, provider fax, requester contact name and phone number (ext.).
Drug details: drug name, strength, quantity per 30 days, and length of therapy requested.
Clinical rationale: primary psychiatric diagnosis, target symptom(s), prior medication trials and outcomes, specific adverse reactions, contraindications, age-specific considerations, and any supporting FDA or peer-reviewed literature references.
Attach relevant clinical notes or objective data supporting trials, intolerances, or contraindications.

Denial Risk

Insufficient Non-Preferred Justification

Insufficient justification for a non-preferred medication increases risk of denial. Requests that lack documentation of trial/failure of preferred agents or a clear clinical contraindication will be at risk for denial.

If failure of preferred drugs is claimed, include specific agents and clinical details demonstrating failure (dates, dose, duration, and reason for discontinuation).
If claiming allergy, drug–drug interaction, or contraindication, describe the reaction or clinical circumstance in detail.
Provide age-specific rationale or cite FDA/peer-reviewed support for unique indications when applicable.

Definitions

Non-preferred medication justification — acceptable reasons documented on form

Failed preferred drugProvider indicates whether the member failed one preferred drug and lists the preferred drugs that failed on the form.

Allergic reactionDocumented allergy to the preferred medication (checkbox and description field provided).

Drug–drug interactionDocument a drug–drug interaction and describe the reaction in the provided free-text field.

Previous unacceptable side effect or therapeutic failureRecord prior episode of unacceptable side effect or therapeutic failure and provide clinical details in the narrative field.

Clinical contraindication/comorbidity or unique patient circumstanceSpecify clinical contraindication, co-morbidity, or unique patient circumstance that contraindicates preferred drug(s) with supporting clinical information.

Age-specific indicationProvide patient age and explain the age-specific reason a preferred drug is unsuitable.

FDA-supported unique indication or unacceptable clinical riskDocument a unique clinical indication supported by FDA approval or literature (include reference) or describe an unacceptable clinical risk associated with switching therapies.

Background

This prior authorization form is used to request approval for psychiatric medications and captures key elements to support medical necessity: beneficiary and prescriber identifiers, the requested drug (name, strength, quantity, length of therapy), the primary psychiatric diagnosis and target symptom, and documentation of informed consent regarding metabolic and neurologic risks. For non-preferred agents the form requires a documented rationale (e.g., failed preferred drug(s), allergy, interaction, unacceptable side effect, contraindication, age-specific indication, FDA-supported unique indication, or unacceptable clinical risk) with space to describe clinical details and to list any preferred drugs that were tried and failed.

OpenPayer

Prior Authorization Form for Non‑Preferred Psychiatric Medications — Coverage Criteria

Coverage Criteria

Provider Actions and Documentation Requirements

Psychiatric Medication Therapy

Definitions

Background