CurrentUnitedHealthcarePolicy N/A

Fertility Preservation (Maryland) Prior Authorization Form - Community Plan

A UnitedHealthcare Maryland prior authorization form to request coverage/authorization for fertility preservation medications and procedures (including cryopreservation of ovarian tissue, oocytes, and sperm) with member, provider, and clinical information fields and attestation. Defines required documentation, age/categories, limits on authorization length and cycles, and submission instructions.

Policy Summary

PayerUnitedHealthcare

PolicyFertility Preservation (Maryland) Prior Authorization Form - Community Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete entire form, attach treatment plan and clinical notes, have prescriber attest and sign, then fax to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form content and requirements remain informational and unchanged.

3 monthsStandard Authorization Length

1One-time benefit (ovarian tissue & sperm)

3Max ovarian stimulation cycles

24Minimum review turnaround (hrs)

Policy Summary

This is the UnitedHealthcare Maryland Community Plan prior authorization form for fertility preservation medications and procedures. The form captures member identification and contact details, provider information (including NPI and specialty), and clinical/medical information including the requested medication(s) from the listed fertility agents and diagnosis details.

It requires documentation of clinical justification: selection of the applicable age category (puberty-to-menopause vs prepubertal/insufficient time for oocyte retrieval), the cause of fertility impairment (surgery, radiation, chemotherapy, or other medical treatment), and attachment of the treatment plan and clinical notes. For cryopreservation of ovarian tissue and sperm, the form requires documentation of cycles received.

Providers must complete and sign the form, including a Prescriber Attestation that FDA precautions/warnings and contraindications (including Black Box Warnings) have been considered, contraindicated medications have been discontinued, and that the benefits outweigh the risks and the information on the form is accurate. Complete forms should be faxed to 866-940-7328 and allow at least 24 hours for review; incomplete forms will not be reviewed.

Key Administrative Facts

Standard Authorization Length3 months

One-time benefit for ovarian tissue and sperm cryopreservation1

Maximum ovarian stimulation/oocyte preservation cycles covered3

Minimum review turnaround24 hours

PayerUnitedHealthcare

Policy TitleFertility Preservation Prior Authorization Form (Maryland)

StatusCURRENT

Eligibility and Documentation Criteria

Authorization Length and Limits

Requests must meet the following informational/eligibility fields and documentation requirements:

All Requests

Age Restriction: Member is within reproductive ages of puberty to menopause (except for ovarian tissue preservation) OR Prepubertal age or insufficient time for oocyte retrieval for ovarian tissue cryopreservation
Provider must indicate which applies
Impairment of fertility: Member has impairment of fertility due to at least one of: Surgery, Radiation, Chemotherapy, or Other medical treatment or intervention affecting reproductive organs or processes
Required documentation: Treatment plan and clinical notes attached to support request
Required documentation
Cycles documented for ovarian tissue and sperm: For cryopreservation of ovarian tissue and sperm, document cycles received
Number of cycles must be documented on form
Prescriber Attestation — select all applicable: All FDA precautions/warnings, contraindications, and Black Box Warnings have been considered; discontinuation of medications that are contraindicated in concurrent use; benefits of treatment for this individual outweigh the risks and the information provided on the form is true and accurate
Provider signature and date required

ref": "b1_0

title": "All Requests"

title_x_invalid_removed_for_schema_compliance___ignore_this_field_DO_NOT_USE": "" } , {

Medications Listed on Form

Drugs listed on form (requested medication)mixed

	Pregnyl (chorionic gonadotropin)
	Ovidrel (choriogonadotropin alfa)
	Novarel (chorionic gonadotropin)
	Follistim AQ (follitropin beta)
	Gonal-f (follitropin alfa)
	Gonal-f-RFF (follitropin alfa/beta)
	Gonal-f-RFF Redi-Ject (follitropin alfa/beta)
	Ganirelix Acetate Injection
	Lupron (leuprolide acetate solution)
	Cetrotide (cetrorelix acetate)

1–10 of 11

1/2

What Providers Must Do

Prior Authorization

Submit completed prior authorization form

Complete the entire prior authorization form and fax it to 866-940-7328. Allow at least 24 hours for review.

Incomplete forms will not be reviewed.

Documentation Required

Attach clinical documentation and treatment plan

Attach the member's treatment plan and relevant clinical notes to support the request.

For cryopreservation of ovarian tissue and sperm, document cycles received on the form.

Documentation Required

Prescriber attestation and signature

Prescriber must attest that FDA precautions/warnings and contraindications were considered, that contraindicated medications have been discontinued when applicable, and that benefits outweigh risks. Prescriber must sign and date the form.

Billing Rule

Authorization duration and limits

Authorizations for fertility preservation procedures requiring preauthorization are granted for 3 months when initial approval criteria are met.

Cryopreservation of ovarian tissue and sperm is a one-time benefit.
A maximum of three cycles of ovarian stimulation and oocyte preservation will be covered.

Policy Summary

PayerUnitedHealthcare

PolicyFertility Preservation (Maryland) Prior Authorization Form - Community Plan

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete entire form, attach treatment plan and clinical notes, have prescriber attest and sign, then fax to 866-940-7328 and allow at least 24 hours for review.

SourceLink

On This Page

OpenPayer

Fertility Preservation (Maryland) Prior Authorization Form - Community Plan

Policy Summary

Eligibility and Documentation Criteria

Medications Listed on Form

What Providers Must Do

Document Changes