CurrentAvMedPolicy Pub. 100-2

Prior authorization and coverage criteria for Prialt (ziconotide) intrathecal therapy

Form and clinical criteria for medical prior authorization and step-edit requests for Prialt (ziconotide) for AvMed members; applies to prescribers requesting coverage for this medication (medical benefit/infusion) and their patients.

Policy Summary

PayerAvMed

PolicyPrior authorization and coverage criteria for Prialt (ziconotide) intrathecal therapy

Policy CodePolicy Pub. 100-2

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed AvMed Medical Prior Authorization/Step-Edit Request form with required prescriber signature, documentation of prior therapies or narcotic abuse, and supporting records; fax to 1-877-535-1391.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

J-2278Drug/Code

Signature + DEA/NPIPrescriber requirements

All criteria must be metApproval logic

PropriumRxSpecialty pharmacy

Coverage Criteria for Prialt (ziconotide)

Initial Authorization Criteria for Prialt (ziconotide)

Covered when ALL of the following are met

Prescriber and psychiatric criteria: Prescriber is a pain management specialist AND member does not have a pre-existing history of psychosis.

Both checkboxes must be checked on form.

Prior therapy requirement: Member has tried and failed other pain therapies including clonidine epidural and Duramorph epidural OR has history of prior and/or current narcotic abuse.

At least one of the two options must be checked.

The policy explicitly states that use of samples to initiate therapy does not meet step-edit/preauthorization criteria. Requests where therapy was started using medication samples are not acceptable evidence of meeting the step-therapy requirement and therefore do not satisfy the prior authorization conditions.

Approval requires that all clinical criteria must be met and that supporting documentation (including lab results, diagnostics, and chart notes) be provided for each checked criterion. Requests that fail to meet every required criterion or lack the necessary supporting documentation may be denied.

Policy Summary

PayerAvMed

PolicyPrior authorization and coverage criteria for Prialt (ziconotide) intrathecal therapy

Policy CodePolicy Pub. 100-2

Change TypeNo material change

Effective Date

Next Review Date

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 and Requirements

Prior Authorization

Prior authorization required for Prialt (ziconotide)

Prior authorization is required for Prialt (ziconotide) (J-2278). Complete the AvMed Medical Prior Authorization/Step-Edit Request form and submit by fax to 1-877-535-1391; all clinical criteria on the form must be met and documented for approval.

Step Therapy

Step-edit: prior therapies required

The prescriber must confirm the patient has tried and failed specified therapies or document narcotic abuse: either tried and failed other pain therapies including clonidine epidural and Duramorph epidural, OR has a history of prior and/or current narcotic abuse. Use of samples to initiate therapy does not meet step-edit/preauthorization criteria.

Documentation Required

Required supporting documentation

Provide supporting documentation for each clinical criterion checked on the form; this includes lab results, diagnostic studies, and chart notes to substantiate the selected criteria.

Documentation Required

Form completion requirements

The prescribing physician must sign and clearly print their name on the request (preprinted stamps are not valid) and include member identifiers and the prescriber's DEA or NPI number; ensure phone and fax contact information is correct.

Denial Risk

Incomplete documentation risks denial

Authorizations can be delayed or denied if the information provided is incomplete, incorrect, or illegible; requests may be denied if supporting documentation for each checked clinical criterion is not provided.

Definitions and Key Terms

Prescriber

RequirementPrescriber must be a pain management specialist (checkbox on form must be checked).

Supporting documentationAll documentation supporting prescriber specialty (chart notes, credentials) must be provided or request may be denied.

Form completionPrescribing physician must sign and clearly print name on the request (preprinted stamps not valid).

Prior therapies

Required prior therapiesTried and failed other pain therapies including clonidine epidural and Duramorph (morphine) epidural.

Alternative to prior therapiesHistory of prior and/or current narcotic abuse can satisfy the step-edit instead of trialing the specified epidural therapies.

Documentation requirementTo support each checked prior-therapy option, provide documentation (chart notes, diagnostics) or request may be denied.

OpenPayer

Prior authorization and coverage criteria for Prialt (ziconotide) intrathecal therapy

Coverage Criteria for Prialt (ziconotide)

Coding

Provider Actions and Requirements

Conservative Treatment / Step Therapy Requirements

Definitions and Key Terms

Background

Not Covered