UnitedHealthcare Medication PA Checklist: One-and-Done Submissions
- Jamie P
- Sep 15
- 8 min read
Medication prior authorization (PA) can feel like a maze—especially when the prescription is urgent, the patient is standing at the pharmacy counter, and the portal keeps bouncing back your request for “more information.” The truth is, most delays are predictable and preventable. With a clean, one-and-done submission—built around the exact clinical elements UnitedHealthcare (UHC) and its pharmacy benefit manager (PBM) reviewers expect—you can turn multi-week stalls into approvals in a handful of business days for routine cases.
This guide gives you a pragmatic, systemized checklist for UHC medication PAs. You’ll get step-by-step intake, a tight one-page medical-necessity template, precise ways to document step therapy and safety labs, and a follow-up rhythm that keeps cases moving. We’ll also include real-world scripts, a mini “PA pod” operating model for clinics, and common pitfalls (with fast fixes) that you can paste straight into your SOP.
What “One-and-Done” Means for UnitedHealthcare Medication PAs
A one-and-done submission isn’t longer—it’s complete and consistent. It includes:
Exact drug metadata: drug name, strength, route, formulation, NDC if required, quantity per fill, days’ supply, and refills
Clear diagnosis details: precise ICD-10 code(s) matched to the indication and severity
Step-therapy history: names, start/stop dates, adherence, outcomes, and adverse events for required predecessors
Safety evidence: baseline labs/diagnostics or screenings tied to the drug’s risk profile (and the monitoring plan)
Clinical rationale: a concise, function-forward justification for this patient and this regimen now
Channeling and routing: correct PBM/plan portal, required specialty pharmacy (if applicable), and patient contact readiness
Do that, and most PAs sail through on the first submission. Miss any single element—especially dates, dose/quantity alignment, or proof of step therapy—and you invite pend/deny loops.
UnitedHealthcare Medication PA, In Plain English
When a UHC member’s pharmacy claim returns “PA required,” it means coverage decisions will be based on plan criteria. Many UHC plans use a PBM workflow (often OptumRx) with plan-specific forms or ePA (electronic prior authorization) questionnaires. Your goal is to answer exactly the criteria the form asks—no more, no less—using short, scannable headings and consistent data across your submission.
Key reality checks:
Different UHC products (commercial, Medicare Advantage, Medicaid) can apply different criteria for the same drug.
Many specialty medications must be filled at a designated specialty pharmacy once approved.
ePA inside your EHR or through a connected portal is typically faster than fax/forms, because it enforces required fields and produces traceable confirmation IDs.
The Fast-Approval Intake Checklist (Do This Before You Submit)
Member & Plan:
Member name, DOB, ID, plan/product (commercial/MA/Medicaid)
Confirm PBM channel and whether specialty pharmacy is required
Drug & Regimen:
Drug name, strength, formulation, route
Quantity per fill and days’ supply (e.g., 2 pens every 28 days)
Dosing/titration plan and expected duration
NDC if the form asks (some plan workflows require it)
Diagnosis & Severity:
ICD-10 code(s) matched to the requested indication
One-paragraph severity snapshot: functional limits, risks, and current status
Treatment History (Step Therapy):
Prior drugs (names), start/stop dates, adherence summary, outcomes, adverse events
Contraindications to plan-preferred alternatives (if applicable)
Safety & Monitoring:
Baseline labs/tests required for the class (e.g., TB screen, LFTs, eGFR) with dates and values
Ongoing monitoring cadence and stop rules
Routing & Contacts:
Confirm specialty pharmacy (if mandated) and capture portal confirmation ID
Patient phone/email verified; let them know to expect calls/texts
Bundle this information into a one-page medical-necessity summary, then attach labs/notes separately with clear file names.
The One-Page Medical-Necessity Summary
Patient / Plan: [Name, DOB, Member ID, product type]
Medication & Regimen: [Drug, strength, route, quantity per fill, days’ supply, titration plan]
Diagnosis & Severity: [ICD-10] + function-forward snapshot (impact on ADLs/risk)
Treatment History:
[Drug A] [dose] [mm/dd/yyyy–mm/dd/yyyy] — adherence ~[x%], outcome [objective metric or narrative], AE [if any]
[Drug B] [dose] [mm/dd/yyyy–mm/dd/yyyy] — [same format]
Safety & Monitoring: [Baseline labs/tests with dates/values; contraindications; monitoring cadence & stop rules]
Clinical Rationale: Why this medication now for this patient (mechanism/phenotype fit, failure or risk with alternatives)
Routing Notes: [PBM/portal confirmation ID, specialty pharmacy if required]
Keep it to one page. Use the same dose and frequency everywhere (form, eRx, note). Mismatches are the #1 cause of pends.
Documenting Step Therapy the Way Reviewers Want
Step therapy isn’t “list a few meds.” It’s specifics:
Names and exact doses
Start/stop dates (approximate is acceptable: “2025-02–2025-04”)
Adherence indicators (e.g., ≥80% of doses)
Objective outcome (e.g., headache days/month, A1c, peak flows, PASI score)
Adverse events with onset and resolution
Reason for discontinuation (ineffective vs. intolerance vs. contraindication)
If you’re seeking a formulary or step-therapy exception, explicitly state the medical reason the plan-preferred option is unsafe, ineffective, or clinically inappropriate for this patient, and attach the supporting evidence.
Safety Evidence That Prevents “Pend for Labs” Emails
Submit the baseline tests the criteria require—on the first pass:
Infectious screens (e.g., TB, hepatitis) for immunomodulators
Organ function labs (e.g., AST/ALT, SCr/eGFR) for hepatotoxic/nephrotoxic risk
Pregnancy status where relevant
EKG/echo or class-specific tests when indicated
Special program compliance (e.g., REMS enrollment if applicable)
List each test with date and result in the one-pager, then attach the actual lab/diagnostic report with a clear filename (e.g., TB-Quantiferon_2025-03-08.pdf).
Channeling and Specialty Pharmacy: Get It Right the First Time
Many UHC plans require certain drugs to be filled through a designated specialty pharmacy after approval. If the form or portal specifies a pharmacy, route the script there immediately once approved. If your eRx and the PA form route to different pharmacies, you’ll trigger avoidable “no fill” loops.
Quick routing sanity check:
Is the plan PBM channel correct in the portal you used?
Does the plan mandate a specific specialty pharmacy for this NDC?
Does the eRx destination match what the plan expects?
If any of these answers are “not sure,” confirm before you submit.
Use ePA First And Make It Work for You
Electronic prior authorization (ePA) inside the EHR or a connected portal speeds decisions because it:
Enforces required fields, reducing missing-data pends
Presents plan-specific questions in order
Generates a confirmation ID and a visible status trail
Level-up tips:
Create smart phrases for common criteria (e.g., step-therapy exception language, TB/LFT blocks)
Pre-build a “medication history” snippet that drops in the names/dates/outcomes format automatically
Always paste the confirmation ID into your tracker and set a follow-up for two business days before the posted decision window closes
Real-World Scripts
Patient → Clinic (At the Counter):
“Hi, this is [Full Name, DOB]. The pharmacy says [Drug, Dose] needs prior auth with my UnitedHealthcare plan. My member ID is [ID], the pharmacy is [Name/Phone]. Could you submit the PA today? I can send a list of prior meds and any labs you need.”
Clinic → Plan/PBM (Status Check):
“Calling about PA for [Patient, DOB, ID, Drug]. Submitted via ePA on [Date], confirmation [ID]. Do you have everything you need? What’s the current status and target decision date? If you need labs or additional notes, I can upload them today.”
Clinic → Specialty Pharmacy (After Approval):
“Authorization obtained for [Drug, Dose, Days’ Supply] for [Patient] under UnitedHealthcare. Please process and contact the patient at [Phone]. Our monitoring plan includes [brief items]; teach visit is scheduled [Date].”
Follow-Up Rhythm That Protects Your Timeline
Day 0 (Submission): Capture confirmation ID; verify patient contact info; set reminders
Day 1–2: If there’s a pend, respond same day with only the requested items and a two-line note listing exactly what you attached
Two Business Days Before Deadline: Status check call or portal message; ask for the decision date
If Denied: Choose peer-to-peer (when it hinges on clinical nuance) or file a tight appeal that quotes the policy and answers it point-by-point
Common Pitfalls And How to Fix Them Fast
Dose/Quantity Mismatch: The eRx says 40 mg daily; the form says 20 mg. Fix: reconcile and resubmit with a one-line note acknowledging the correction.
Vague Step Therapy: “Tried other meds” gets pended. Fix: add drug names, dates, adherence, outcomes, and adverse events.
Missing Safety Labs: Criteria require TB/LFTs but nothing’s attached. Fix: upload lab reports with dates/values and reference them in your one-pager.
Wrong Pharmacy Channel: Approval granted, but the script isn’t at the designated specialty pharmacy. Fix: re-route immediately; document the new pharmacy and inform the patient.
Unreachable Patient: The specialty pharmacy can’t schedule the first fill. Fix: verify phone/email at intake and tell the patient to expect calls/texts.
Build a Mini “PA Pod” That Scales With Your Clinic
You don’t need a big team—just clear ownership and repeatable checklists.
Intake & Routing Lead: Confirms plan/PBM, specialty-pharmacy rules, launches ePA, logs confirmation IDs
Clinical Packager: Crafts the one-page summary, compiles labs and prior-meds history, checks for contradictions
Tracker & Escalations: Monitors turnaround windows, responds to pends the same day, schedules P2Ps/appeals
Run a 15-minute weekly huddle to review “Pending > 3 Business Days” and eliminate the top three causes of delay. Track: first-submission approval rate, average days to decision, percent pended for missing info, P2P win rate.
Specialty Medications: Extra Steps That Save Days
Specialty therapies add logistics (cold chain, injection teaching, financial assistance). Start these in parallel with the PA:
Enroll in manufacturer assistance (copay, bridge) the day you submit the PA
Schedule teach visits at approval (don’t wait for the shipment to arrive)
Confirm delivery windows with patient/caregiver; verify address and storage requirements
Set refill reminders at day 21–23 of a 28-day cycle to surface issues early
Medicare, Medicaid, and Commercial Nuances: What to Expect
Medicare Advantage: Expect strict adherence to coverage indications and redetermination processes; ensure compendia/guideline justification is tight.
Medicaid: State-specific criteria and preferred drug lists (PDLs) can differ; follow the state’s step-therapy logic closely and document contraindications.
Commercial: Employer-specific designs may tweak rules; always use the plan-specific portal flow and language.
Regardless of product, the one-page format + exact evidence is your fastest path to “approved.”
A One-Week Sprint to Cut Decision Times
Day 1: Add smart phrases for step therapy, labs, and the one-page format into your EHR
Day 2: Build a simple tracker with columns for confirmation ID, due date, status, next action
Day 3: Map top 10 drugs’ criteria and specialty pharmacy rules for your panel
Day 4: Pilot ePA on two plans; capture IDs and document your average time to decision
Day 5: Review pended cases; fix causes (dose mismatch, missing labs) and update your templates
Repeat next week. Small improvements compound quickly.
Frequently Asked Questions
Do I always need the NDC?
Not always. Some forms and portal flows require it; others accept drug name/strength alone. If the form asks, include the NDC that matches your eRx to avoid mismatches.
Can I skip step therapy?
If a plan-preferred drug is contraindicated or has already failed, request a formulary/step-therapy exception with dates, outcomes, and risks.
How long will the decision take?
Turnarounds vary by product and completeness. ePA with a complete packet often yields decisions in several business days. Set a follow-up before the posted window closes.
What if the patient changes insurance mid-therapy?
You’ll likely need to repeat PA with the new plan. Ask about transition-of-care options to prevent gaps.
Do approvals expire?
Yes—many PAs approve a 6–12 month window. Put re-auth reminders on your calendar.
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