CurrentUnitedHealthcarePolicy N/A

Wa Cystic Fibrosis Agents Oral Prior Auth Form

A Washington state prior authorization request form for oral cystic fibrosis agents administered under UnitedHealthcare; collects member, provider, diagnosis, mutation and prior therapy information to determine medical necessity for new or continuation therapy.

Policy Summary

PayerUnitedHealthcare

PolicyWa Cystic Fibrosis Agents Oral Prior Auth Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must complete entire prior authorization form including Sections A-E and fax to 866-940-7328; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

Mutation listCovered Responsive Mutations (listed)

UnspecifiedForm length

Coverage Summary

This is a Washington state prior authorization request form from UnitedHealthcare for oral cystic fibrosis agents. Coverage stance: covered_with_criteria. The form collects member and provider details, diagnosis and ICD-10 code, CFTR mutation information, and prior therapy/medication trial data to determine medical necessity for new or continuation therapy.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Submit completed prior authorization form

Complete Sections A-E on the prior authorization form and fax the entire form to 866-940-7328. Allow at least 24 hours for review. Be sure the form includes requested medication name, strength, directions, quantity, the diagnosis with ICD-10 code, prior medication trials information, documentation of CFTR mutation status, and pregnancy status where applicable.

Documentation Required

Genetic mutation documentation

Document either that the patient is homozygous for F508del (two copies) OR that the patient has at least one CFTR mutation that is responsive to the requested medication potentiation. The form includes a list of specific CFTR mutations for reference.

Documentation Required

Previous medication trials

If the patient has failed or is intolerant to preferred oral cystic fibrosis agents, complete Section D with the medication name, strength, directions, dates of therapy, and the reason for failure or discontinuation.

Documentation Required

Continuation evidence

For continuation requests, indicate either significant improvement in FEV1 from baseline or stabilization of disease on the form, and provide the provider signature and date.

Background

This prior authorization form is used to collect clinical information, genetic mutation data, and prior therapy details to support medical necessity determinations for oral cystic fibrosis agents; it includes Sections A–E for member, provider, medical, prior medication trials, and additional information. The form provides an extensive reference list of CFTR gene mutations and asks whether the patient is homozygous for F508del or has at least one mutation responsive to the requested medication.

F508del: a specific CFTR gene mutation; the form requests confirmation of two copies (homozygous) as applicable.

Policy Summary

PayerUnitedHealthcare

PolicyWa Cystic Fibrosis Agents Oral Prior Auth Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must complete entire prior authorization form including Sections A-E and fax to 866-940-7328; allow at least 24 hours for review.

SourceLink

On This Page

OpenPayer

Wa Cystic Fibrosis Agents Oral Prior Auth Form

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Prior Authorization Requirements

Background