CurrentUnitedHealthcarePolicy N/A

Androgen Biosynthesis Inhibitors: Abiraterone prior authorization form and clinical questionnaire

This document is a UnitedHealthcare prior authorization request form and clinical questionnaire for androgen biosynthesis inhibitor abiraterone (generic and brand formulations) describing required member, provider, clinical information, diagnoses, regimen details, combination therapy, and documentation required to support coverage decisions.

Policy Summary

PayerUnitedHealthcare

PolicyAndrogen Biosynthesis Inhibitors: Abiraterone prior authorization form and clinical questionnaire

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and fax the full abiraterone prior authorization form (all sections) to 866-940-7328 and include chart notes, labs, and test results to avoid delays.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

3Primary Indications Listed

866-940-7328Required Form Fax Number

3Required Documentation Types

Coverage Summary

This policy is covered_with_criteria (status: CURRENT). Effective/status metadata: UnitedHealthcare prior authorization form for abiraterone that requires completion of all sections and prescriber signature to support medical necessity decisions. The high-level purpose is to serve as a UHC prior authorization form and clinical questionnaire for abiraterone assessing diagnoses, regimen details, combination therapy, surgical/hormone status, and required documentation to support coverage decisions. Quick highlights: Primary Indications Listed: 3 (metastatic castration resistant prostate cancer; metastatic high-risk castration sensitive or castration naive prostate cancer; non-metastatic high-risk prostate cancer), Required Form Fax Number: 1 (866-940-7328), and Required Documentation Types: 3 (chart notes, laboratory results, and test results).

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Medical-Necessity Criteria (Prior Authorization Requirements)

General Requirements for Approval

Approval is contingent on completion of form sections and meeting diagnosis-specific criteria; chart notes, labs and test results are required.

ALL of the following

Completed prior authorization form with Sections A-D and prescriber signature
Form must be faxed to 866-940-7328
Diagnosis specified with corresponding ICD-10 code
Diagnosis options include metastatic castration resistant prostate cancer; metastatic high-risk castration sensitive or castration naive prostate cancer; non-metastatic high-risk prostate cancer; other (specify)
Documentation of whether request is new therapy or continuation of therapy
If continuation, provide start date and documentation of disease stability or improvement compared to baseline measures
Prescriber is an oncologist or urologist, or in consultation with one
Form asks whether prescribed by or in consultation with oncologist/urologist
Concomitant use of steroid consistent with FDA labeling (e.g., prednisone with Zytiga, methylprednisolone with Yonsa)
Member must be receiving steroid per labeling
Chart notes, laboratory results and test results included with request
Required for decision

Surgical / Hormone Suppression Requirements

One of the following

Patient has had bilateral orchiectomy
If no orchiectomy, patient will receive concurrent hormone suppression (e.g., GnRH therapy)

Formulation Preference

Request indicates whether generic abiraterone 250 mg tablets are being requested

If not requesting 250 mg tablets, provide documented clinical rationale that 250 mg tablets are not an effective regimen for this patient

Criteria for Metastatic High-Risk Castration Sensitive or Castration Naive Prostate Cancer

For this diagnosis, at least one listed risk factor should apply:

ANY of the following

Gleason score ≥ 7 (Grade Group > 2)
Bone lesions
Presence of measurable visceral metastases

If used in combination with docetaxel: Patient has high-volume metastatic burden

Yes/No to be indicated

Criteria for Non-metastatic High-Risk Prostate Cancer

Node negative or node positive definitions and additional high-risk features

Node positive indicated

Node negative: at least one of

Gleason score > 8
Tumor stage T3 or T4
Prostate-specific antigen (PSA) concentration ≥ 20 ng/mL≥ 20 ng/mL
PSA doubling time < 6 months or PSA ≥ 20 ng/mLPSA doubling time < 6 months

Provider Actions / Prior Authorization Steps

Prior Authorization

Submit completed prior authorization form

Providers must complete and fax the full abiraterone prior authorization form (all sections) to 866-940-7328 and include chart notes, labs, and test results to avoid delays.

Fax number: 866-940-7328
Required attachments: chart notes, laboratory results, and test results

Documentation Required

Support continuation requests with clinical response

For continuation requests, submit clinical documentation demonstrating disease stability or improvement compared to baseline measures and specify which measures are being used to define response.

Submit documentation showing disease stability or improvement compared to baseline
Specify the measures used to define response (e.g., PSA, imaging, clinical assessment) as indicated on the form

Documentation Required

Provide rationale for non-preferred formulation

If requesting a formulation other than generic abiraterone 250 mg tablets, provide a documented clinical rationale that 250 mg tablets are not an effective regimen for this patient.

Provide documented clinical rationale why 250 mg tablets would not be effective for this patient

Documentation Required

Confirm concurrent therapies and surgery status

Document whether the patient has had a bilateral orchiectomy or, if not, that the patient will receive concurrent hormone suppression (e.g., GnRH therapy). Also document whether abiraterone will be used with a steroid consistent with FDA labeling.

Indicate bilateral orchiectomy status (Yes/No) or plan for concurrent hormone suppression (e.g., GnRH therapy)
Document concomitant steroid use consistent with FDA labeling (e.g., prednisone with Zytiga, methylprednisolone with Yonsa)

Background

This document is a multi-page prior authorization and clinical questionnaire used by UnitedHealthcare to assess medical necessity for abiraterone therapy across several prostate cancer indications. The form captures whether the request is new or a continuation (with dates and documentation of disease stability or improvement), specific diagnosis selection with ICD-10 coding, prior medication trials and rationale for non-preferred formulations, prescriber specialty/consultation (oncologist or urologist), surgical status (bilateral orchiectomy) or concurrent hormone suppression (e.g., GnRH), concurrent steroid use per FDA labeling, risk factors for metastatic high-risk castration sensitive/naive disease (e.g., Gleason score ≥7, bone lesions, measurable visceral metastases), node status and high-risk features for non-metastatic high-risk disease (e.g., Gleason score >8, tumor stage T3/T4, PSA ≥ 20 ng/mL, PSA doubling time < 6 months), combination therapy with EBRT, ADT, or prednisone/prednisolone, and an explicit requirement that chart notes, labs and test results are required with the request.

Definitions and thresholds

Definition - GnRHGonadotropin-releasing hormone; used in androgen deprivation therapy.

PSA concentration threshold≥ 20 ng/mL

PSA doubling time threshold< 6 months

OpenPayer

Androgen Biosynthesis Inhibitors: Abiraterone prior authorization form and clinical questionnaire

Coverage Summary

Medical-Necessity Criteria (Prior Authorization Requirements)

Coding

Provider Actions / Prior Authorization Steps

Background

Revision History