CurrentUnitedHealthcarePolicy N/A

Prescription prior authorization form for BPH medication

Form governing prior authorization requests for a drug to treat benign prostatic hyperplasia (BPH); used by prescribers to request coverage for a specific medication for UnitedHealthcare beneficiaries. Affects adult male patients and prescribing providers submitting PA requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrescription prior authorization form for BPH medication

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including patient identifiers, prescriber signature, drug details, confirmation of male sex and age ≥18, BPH diagnosis, and documentation of prior medication trials or contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum beneficiary age required

malerequired beneficiary sex

2preferred medications tried

1alpha blocker among prior meds

Coverage Criteria

Approval criteria

Covered when ALL of the following are met

Age: Beneficiary is 18 years of age or older>=18 years

Sex: Beneficiary is malemale

Diagnosis: Confirmed diagnosis of Benign Prostatic Hyperplasia

Current therapy: Documentation whether beneficiary is currently receiving an alpha blocker or nitrate (for clinical context)

Policy Summary

PayerUnitedHealthcare

PolicyPrescription prior authorization form for BPH medication

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required before dispensing the requested medication. Complete the UnitedHealthcare prior authorization process and submit the completed PA form with all required fields and prescriber signature. Treatments without an approved prior authorization may be denied or subject to retrospective review.

Submit PA form before service or drug fill
Include drug name, strength, quantity per 30 days, and length of therapy

Denial Risk

Triggers for Denial

The PA request will be denied if required identifying information or the prescriber signature is missing, or if required clinical information and prior medication trials are not documented. Incomplete forms (missing beneficiary name/ID/DOB/gender, missing prescriber NPI, or absent requester contact) are triggers for denial.

Missing prescriber signature or date
Missing beneficiary identification (name, ID number, DOB, gender)
Missing prescriber NPI or requester contact information
Failure to document required prior medication trials or clinical contraindications

Documentation Required

Required Documentation on PA Form

The PA form must include complete prescriber and beneficiary information and be signed by the prescriber. Provide the drug details and therapy duration, and document prior treatment history or clinical reasons for exception.

Prescriber signature and date (mandatory)
Beneficiary name, UnitedHealthcare ID number, date of birth, and gender
Prescribing provider NPI number
Requester contact name and phone (include extension if applicable)
Drug name, strength, quantity per 30 days, and requested length of therapy (select or specify days)
Documentation of diagnosis (e.g., confirmed benign prostatic hyperplasia) and current therapies

Step Therapy

Step Therapy Requirement

Step therapy applies: the beneficiary must have tried and failed at least two preferred medications (including at least one alpha blocker and at least one hormone blocker) unless there is a documented clinical reason or contraindication explaining why these preferred agents cannot be used.

Document specific medications tried and dates of therapy
If exceptions claimed, provide clinical reason or contraindication for not using preferred agents

Background

This PA form is used to request coverage for a medication to treat Benign Prostatic Hyperplasia (BPH) in adult male beneficiaries. It collects beneficiary identifiers and demographics, confirmation that the beneficiary is 18 years of age or older and male, documentation of a confirmed BPH diagnosis, current use of alpha blockers or nitrates, and prior therapy information including whether the beneficiary has tried and failed at least two preferred medications (specifying that at least one was an alpha blocker and at least one a hormone blocker) or a documented clinical reason/contraindication why those agents cannot be used. The form also requires prescriber signature and drug-specific details (name, strength, quantity per 30 days, and requested length of therapy).

Definitions

BPH — Benign Prostatic Hyperplasia (diagnosis and requirements)

TermBenign Prostatic Hyperplasia (BPH)

DefinitionClinical diagnosis provided by the prescriber that justifies treatment for BPH.

Required beneficiary age18 years or older

Required beneficiary sexMale

Documentation requiredPrescriber must confirm diagnosis of BPH and sign the form (Prescriber signature mandatory).

Prior therapy requirementMust have tried and failed ≥2 preferred medications (≥1 alpha blocker and ≥1 hormone blocker) OR document clinical reason/contraindication why these cannot be used.