CurrentUnitedHealthcarePolicy N/A

Androgen Biosynthesis Inhibitors [Abiraterone, Yonsa, Zytiga] (Washington) Prior Authorization Form - Community Planopen_in_new

A prior authorization request form for androgen biosynthesis inhibitors (abiraterone products) used in prostate cancer indications for UnitedHealthcare Washington Community Plan; collects member, provider, diagnosis, prior therapy, concurrent therapy, and clinical justification information to support PA decisioning.

Policy Summary

PayerUnitedHealthcare

PolicyAndrogen Biosynthesis Inhibitors [Abiraterone, Yonsa, Zytiga] (Washington) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeAdministrative (PA form)

Effective Date

Next Review Date

Key ActionProviders must complete the entire PA form and fax it to 866-940-7328 (or call 800-310-6826 for questions) and include chart notes, labs and test results; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

1Form pages (multi-page indicated)

3Primary diagnosis categories listed

4Concurrent therapy checkboxes

Policy overview

This is a prior authorization form for androgen biosynthesis inhibitors (abiraterone formulations including Zytiga, Yonsa, and generics) for prostate cancer indications under the UnitedHealthcare Washington Community Plan. The form captures member and provider information, diagnosis details (including ICD-10), prior medication trials, concurrent therapy (e.g., steroids, ADT, EBRT), and clinical justification (including chart notes, labs, and test results) to support PA review. The form references the Apple Health Preferred Drug List for preferred alternatives.

Key details

PayerUnitedHealthcare

PolicyAndrogen Biosynthesis Inhibitors (Abiraterone, Yonsa, Zytiga) PA Form - Washington Community Plan

StatusCURRENT

Scope summaryA prior authorization request form for androgen biosynthesis inhibitors (abiraterone products) used in prostate cancer indications for UnitedHealthcare Washington Community Plan; collects member, provider, diagnosis, prior therapy, concurrent therapy, and clinical justification information to support PA decisioning.

Form pages1

Form sections and required fields

Form Sections and Required Information

The PA form collects required fields and clinical criteria to support coverage review; completion of all pages and submission of chart notes/labs/tests is required.

Top-level form sections and required items

Section A - Member information: First/last name, member ID, address, phone, DOB, allergies, primary insurance, new vs continuation of therapy, hospitalization status, discharge date if applicable
Supports identification and therapy status
Section B - Provider information: Provider name, M.D./D.O. status, address, phone, fax, NPI, specialty, office contact
Section C - Medical information: Medication, strength, directions, quantity, specific diagnosis, ICD-10 code, pregnancy status
Section D - Previous medication trials: List prior medication trials with strength, directions, dates of therapy, and reason for failure/discontinuation
Include explanation why preferred meds would not meet patient's needs per PDL
Section E - Additional information: Explanation of why preferred medications would not meet the patient's needs; refer to PDL for preferred alternatives
Continuation requests: If continuation, document disease stability or improvement compared to baseline measures and provide start date of requested dose
Clinical documentation required
Diagnosis selection: Select one: metastatic castration resistant; metastatic high-risk castration sensitive/naïve; non-metastatic high-risk; or other (specify). Indicate stage
Prescriber information and consultation: Indicate if prescribed by or in consultation with an oncologist or urologist
Orchiectomy / hormone suppression: Indicate whether bilateral orchiectomy performed or whether concurrent hormone suppression (e.g., GnRH therapy) will be used
Concurrent steroid use: Confirm Abiraterone will be used with a steroid consistent with FDA labeling (e.g., prednisone with Zytiga, methylprednisolone with Yonsa)
Generic 250 mg tablets rationale: Is request for generic abiraterone 250 mg tablets? If no, provide documented clinical rationale why 250 mg tablets are not an effective regimen
Metastatic high-risk castration sensitive/naïve risk factors
- Gleason score ≥ 7 (Grade Group > 2)Gleason ≥ 7 (Grade Group > 2)
- Bone lesions
- Visceral metastases: Presence of measurable visceral metastases
- Docetaxel combination high-volume: If used with docetaxel, indicate high-volume metastatic burden
Non-metastatic high-risk prostate cancer criteria
- Node positive
- Node negative high-risk features
  - Gleason score (non-metastatic): Gleason score ≥ 8Gleason ≥ 8
  - Tumor stage T3 or T4T3 or T4
  - PSA concentration high: Prostate-specific antigen (PSA) concentration ≥ 40 ng/mLPSA ≥ 40 ng/mL
Concurrent therapy checkboxes: Will Abiraterone be used with EBRT (unless contraindicated), ADT (e.g., GnRH analogs), and prednisone or prednisolone?
Required supporting documentation and signature: Chart notes, labs and test results are required with the request; prescriber signature, specialty, and date required
Forms lacking documentation may delay or be denied

Administrative submission instruction: Complete entire form and fax to 866-940-7328; questions call 800-310-6826; allow at least 24 hours for review

Includes PDL reference for preferred alternatives

Explicit numeric thresholds

Gleason score≥ 7 (Grade Group > 2) for metastatic high-risk; ≥ 8 for non‑metastatic node‑negative high‑risk

PSA concentration≥ 40 ng/mL (non‑metastatic node‑negative high‑risk) or PSA ≥ 20 ng/mL on ADT or PSA doubling time <6 months

What providers must do

Prior Authorization

Submit completed PA form and supporting documentation

Complete all pages of the PA form and submit the form plus supporting chart notes, labs, and test results. Fax the completed form to the number below or call the phone number for questions. Allow at least 24 hours for review.

Fax: 866-940-7328
Phone: 800-310-6826

Documentation Required

Provide prior medication trials and rationale for alternatives

List prior medication trials, including medication names, dates of therapy, and the reason each was discontinued or considered a failure. Also provide an explanation of why preferred medications on the PDL would not meet the patient's needs.

Documentation Required

Confirm concurrent therapies and roles

Document whether the therapy was prescribed by or in consultation with an oncologist or urologist, whether the patient has had a bilateral orchiectomy or will receive concurrent hormone suppression (e.g., GnRH therapy), and confirm that abiraterone will be used with an appropriate steroid consistent with FDA labeling (for example prednisone with Zytiga or methylprednisolone with Yonsa).

Denial Risk

Incomplete submission may delay or result in denial

Chart notes, labs, and test results, as well as the prescriber's signature, specialty, and date are required. Missing these required clinical documents or information may delay review or result in denial.

OpenPayer

Androgen Biosynthesis Inhibitors [Abiraterone, Yonsa, Zytiga] (Washington) Prior Authorization Form - Community Planopen_in_new

Policy overview

Form sections and required fields

Requested diagnosis coding fields

What providers must do

Who and what this form applies to

Background and reference resources

Document revision history