CurrentUnitedHealthcarePolicy N/A

Clinical Information Form

A prescriber-completed clinical information form used by UnitedHealthcare to collect patient, prescriber, and clinical details to support pharmacy prior authorization requests for a drug (likely for benign prostatic hyperplasia therapies). It captures beneficiary identifiers, drug specifics, therapy duration, and checklist clinical criteria.

Policy Summary

PayerUnitedHealthcare

PolicyClinical Information Form

Policy CodePolicy N/A

Change TypeInformational form (no coverage change)

Effective Date

Next Review Date

Key ActionPrescriber must complete all beneficiary and clinical fields, list prior medications or contraindications if applicable, and provide mandatory signature certifying accuracy.

POLICY UPDATE CHANGES

No material clinical/coverage changes

5Form Required Core Questions

7Identifying Fields Collected

Policy summary and purpose

This is a prescriber-completed clinical information form used by UnitedHealthcare to collect patient demographics, prescriber information, the requested drug and dosing details, therapy duration, and specific clinical questions related to benign prostatic hyperplasia to support pharmacy prior authorization decisions.

The form's purpose is to gather the clinical and identifying information a pharmacy prior authorization reviewer needs to evaluate coverage for therapies related to benign prostatic hyperplasia; it is not a procedural instruction document but a data collection tool completed and signed by the prescriber.

Coverage stance and clinical checklist

Coverage stance: informational. This form is used to provide clinical information to support pharmacy prior authorization determinations.

Clinical Eligibility Questions on Form

Prescriber must indicate responses to all of the following checklist items:

ALL of the following

Beneficiary is 18 years of age or older
Yes/No checkbox required
Beneficiary is male
Yes/No checkbox required
Confirmed diagnosis of Benign Prostatic Hyperplasia
Yes/No checkbox required
Beneficiary is currently receiving an alpha blocker or nitrate
Yes/No checkbox required
Prior therapy or contraindication
- Beneficiary has tried and failed on at least two preferred medications (at least one alpha blocker and at least one hormone blocker)
- Beneficiary has a clinical reason or other contraindication why two preferred medications (at least one alpha blocker and at least one hormone blocker) cannot be tried
  Prescriber must list medications tried or provide clinical reason/contraindication in text area

ref": "b1_1

title": "Clinical Eligibility Questions on Form

Therapy Duration Options

Length of Therapy (days)up to 30, 60, 90, 120, 180, 365, Other

What the prescriber must do

Documentation Required

Prescriber must complete form and sign

Prescriber must complete all beneficiary and clinical fields on the form, including full beneficiary identifiers and prescriber information. Where prior therapy is asked, list medications tried or provide a clinical reason/contraindication in the provided text area. Prescriber signature is mandatory and certifies that the information is accurate and complete.

Complete beneficiary identifiers and prescriber information
List prior medications tried or state contraindication
Provide signature

Prior Authorization

Pharmacy prior authorization request initiation

Use this completed form to support pharmacy prior authorization requests. For assistance with pharmacy PA submissions, contact the Pharmacy PA Call Center at 1-855-258-1593.

Fields collected on the clinical information form

At a glance, the form collects beneficiary identifiers and demographics including last name, first name, beneficiary ID number, date of birth, and gender, plus prescriber identifiers and contact information such as the prescribing provider NPI and requester phone details.

It also captures the requested drug details (drug name, strength, quantity per 30 days), the Length of Therapy (days) with options including up to 30, 60, 90, 120, 180, 365, Other, and a checklist of clinical questions focused on benign prostatic hyperplasia and prior therapy (age ≥18, male, confirmed BPH diagnosis, current alpha blocker or nitrate use, and prior trials or contraindications to at least two preferred medications including at least one alpha blocker and one hormone blocker).