Form Pca18560 - 17-Alpha-Hydroxyprogesterone Caproate (17-P) / Makena Prior Authorization

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17-alpha-hydroxyprogesterone caproate (17-P) / Makena
Prior Authorization Form
Please complete this form for UnitedHealthcare members needing a Makena prescription.
Fax the completed form to UnitedHealthcare at 800-743-6829.
UnitedHealthcare will notify you and your patient of prescription approval.
This form helps UnitedHealthcare determine if the patient’s condition meets our drug policy guidelines.
Please fill out the form completely. Any missing information may cause a delay in the approval.
Fax: 800-743-6829 | Phone: 866-604-3267
Patient Information
Patient’s Name: ________________________________________________________________________ Gender:
M
F
Insurance ID: ____________________________________________ Date of Birth: _________________ Weight: __________________________
Address: _____________________________________________________________________________
Apartment #: _____________________
City: ___________________________________________________
State: _______________________ Zip Code: ________________________
Phone Number: __________________________________________
Alternate Phone Number: _________________________________________
Please attach the front and back side of the member’s insurance card.
Prescriber Information
Name: _________________________________________________
Tax ID: ________________________________________________________
Address: _____________________________________________________________________________
Suite #: _________________________
City: ___________________________________________________ State: _______________________
Zip Code: ________________________
Phone Number: __________________________________________ Fax Number: ___________________________________________________
Office Contact: __________________________________________
Contact Phone / Extension: ________________________________________
Diagnosis Information
Please attach clinical information supporting stated diagnosis, including medication(s) previously tried and failed, and laboratory reports.
Reference drug policy for diagnosis specific requirements at
O20.0 – Threatened abortion
Z87.51 – Personal history of pre-term labor
O09.212- Supervision of pregnancy with history of
O60.02 – Preterm labor without delivery, second trimester
pre-term labor, second trimester
O09.213- Supervision of pregnancy with history of
O60.03 – Preterm labor without delivery, third trimester
pre-term labor, third trimester
O60.10X0 – Preterm labor with preterm delivery, unspecified
Other___________________________________________________
trimester, not applicable or unspecified.
Clinical Information
Is the patient new to therapy:
Yes, requested start date: _________________________________________
No
If no, provide the following:
Start date: __________________
Date of last dose: _____________
Will the physician supply the medication?:
Yes
No
If no, who will supply the medication?: ______________________________________________________________________________________
Site of care:
Infusion Center
Physician’s Office
Home Health with Nursing (Name, Address, City, State, Zip) ___________________________________________________________________
Duration of treatment: _____________________________________________________________________________________________________
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