CurrentUnitedHealthcarePolicy N/A

Nc Cialis Pa Form

A prescriber-completed prior authorization form to request coverage of Cialis for a beneficiary; collects patient and prescriber details and documents clinical criteria (age, sex, diagnosis, concurrent meds, prior therapy failures or contraindications). It governs prior authorization submission requirements rather than providing full policy criteria or billing codes.

Policy Summary

PayerUnitedHealthcare

PolicyNc Cialis Pa Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization form including beneficiary demographics, prescriber NPI, drug details, requested length of therapy, and responses showing criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Form Pages / Document

Coverage Summary

This form governs prior authorization submission requirements for coverage of Cialis for management of Benign Prostatic Hyperplasia (BPH) in male beneficiaries aged 18 years and older. It is a prescriber-completed prior authorization form that collects patient demographics and prescriber details and documents the clinical criteria required for the request, including age (≥ 18), sex (male), confirmed BPH diagnosis, current concurrent medications (alpha blocker or nitrate), and documentation of prior therapy failures or contraindications.

Prior Authorization Criteria

Request requires confirmation of ALL of the following:

ALL of the following

Beneficiary is 18 years of age or older
Checkbox on form
Beneficiary is male
Checkbox on form
Beneficiary has a confirmed diagnosis of Benign Prostatic Hyperplasia (BPH)
Checkbox on form
Is the beneficiary currently receiving an alpha blocker or nitrate?
Yes/No checkbox; documents potential drug interaction/contraindication
ONE OF
- Beneficiary has tried and failed 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
Prescriber signature certifying accuracy
Mandatory signature block on form

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title

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Provider Actions

Prior Authorization

Submit completed PA form

Prescriber must complete and sign the prior authorization form. The completed form must include beneficiary demographics (last name, first name, beneficiary ID, date of birth, gender), prescriber NPI, requester contact, drug name, strength, quantity per 30 days, requested length of therapy (selectable options up to 365 days or Other), and responses to the clinical questions on the form.

Documentation Required

Document prior medication trials or contraindications

Prescriber must list medications tried — including at least one alpha blocker and at least one hormone blocker — or provide clinical reasons/contraindications explaining why these preferred medications cannot be used. The form provides space to list medications tried or the clinical reason/contraindication.

Denial Risk

Risk of denial for missing/signature/criteria

Requests may be denied if the form lacks required fields or the mandatory prescriber signature, or if the form does not demonstrate that the beneficiary meets required criteria: age (18+), sex (male), confirmed diagnosis of BPH, current concurrent medication status (alpha blocker or nitrate), and documentation of prior therapy trials or applicable contraindications.

Definitions

Preferred medications are defined on the form as requiring documentation that the beneficiary has tried and failed on at least two preferred medications, which must include at least one alpha blocker and at least one hormone blocker. The prescriber must list the medications tried or provide a clinical reason/other contraindication explaining why these preferred medications cannot be used.

Background

This is a prescriber attestation form used to request prior authorization for Cialis for management of benign prostatic hyperplasia in male patients aged 18 and older. The form captures required clinical information and prescriber signature, including beneficiary name/ID/DOB/gender, prescriber NPI and contact information, drug name/strength/quantity/length of therapy, confirmation of age, sex, and confirmed BPH diagnosis, current use of an alpha blocker or nitrate, and documentation of prior treatment trials or clinical contraindications for preferred medications.