Submit drug authorization form and clinical documentation

Providers must submit a completed drug authorization request form plus supporting clinical documentation (e.g., lab values, prescription history, statement of medical necessity) via fax to 1305-671-0200 or through the AvMed website to obtain prior authorization. Decisions are generally returned within 24 hours for urgent requests and within 1–3 business days for standard requests.

• Submit completed drug authorization request form and supporting clinical documentation
• Include lab values, prescription history, statement of medical necessity or other pertinent information
• Fax to 1305-671-0200 or submit via AvMed website

Request QL exception with medical necessity statement

If a prescription exceeds a listed quantity limit, the prescriber must provide a statement of medical necessity and request a quantity limit exception through the prior authorization process.

• Provide a statement of medical necessity supporting the exception request
• Request the exception via the standard prior authorization submission channels

Support non‑formulary requests with medical records and necessity

Non‑formulary medication requests must be supported by medical record documentation showing a statement of medical necessity, contraindications to all formulary alternatives, or therapeutic failure of adequate trials (1–3 months) of each formulary alternative, submitted through the prior authorization process.

• Include medical record documentation and/or prescription history
• Document contraindications to ALL formulary alternatives or therapeutic failure after adequate trials (1–3 months)

Submit clinical documentation for CED medications

Medications labeled CED require the prescriber to submit clinical documentation to establish medical necessity over comparable formulary alternatives and are subject to prior authorization.

• Provide clinical justification that the CED medication is necessary over formulary alternatives
• Submit documentation via the prior authorization process

Obtain PA before dispensing when indicated

Prior authorization (PA) is required for certain drugs; the member or ordering prescriber must obtain approval from AvMed before the prescription will be covered.

• Obtain PA approval prior to dispensing when ‘PA’ is indicated on the formulary
• Use the AvMed drug authorization request form and submit required supporting documentation

Follow step therapy trials or document reason to bypass

Step therapy (ST) may require that specified drugs be tried first; if a required trial cannot be completed for clinical reasons, the prescriber may request prior authorization to bypass step requirements.

• Attempt required first‑line agent(s) per ST before requesting alternative coverage
• If trials cannot be completed, request PA and document medical reasons

Adhere to listed quantity limits or request exception

Quantity limits shown on formulary lines are enforced (examples include QL (1 per 1 day), QL (28 per 365 days), QL (6 per 28 days)); if prescribing beyond these limits, prescribers must request a PA/QL exception with supporting documentation.

• Observe numeric QL formats (per day, per 28/30/365 days) listed per product
• Request PA and provide medical necessity documentation to exceed QL

Follow requirement flags shown on formulary lines

Formulary entries include requirement flags such as PA, SP, QL, ST, LA, CED and ACA; when a flag appears next to a product the prescriber must follow the associated process (e.g., obtain PA when ‘PA’ is shown).

• Check product line for requirement/limit codes before prescribing or dispensing
• Follow indicated processes for PA, SP (specialty pharmacy), ST, LA, CED

Verify and act on authorization indicators in drug listings

Drug listing rows include explicit authorization indicators (e.g., PA, SP, LA, ST, QL); prescribers should verify these indicators and submit prior authorization and supporting documentation when PA or specialty handling is required.

• Verify Requirements / Limits codes on the formulary entry
• Submit PA documentation when ‘PA’ is indicated and route specialty items per SP/LA instructions

Comply with PA, SP, and site limitations where shown

Many drugs in the formulary segment require prior authorization, specialty pharmacy handling and/or quantity limits as specified per product; prescribers must obtain PA and comply with specialty/site restrictions where noted.

• Obtain PA for products marked ‘PA’ before dispensing
• Refer specialty items to participating specialty pharmacies when ‘SP’ or ‘LA’ is indicated

Meet utilization control requirements for coverage

The formulary uses multiple utilization controls—PA, ST, SP, LA, CED and QL—for coverage decisions; prescribers must meet the listed requirements (e.g., trials, documentation, PA) to secure coverage.

• Complete required step therapy trials when ST is indicated
• Provide requested clinical documentation and obtain PA for coverage

Follow PA/SP/LA processes for products with specific controls

Examples of specific controls appear on product lines (e.g., EPIDIOLEX: PA; SP; LA; FINTEPLA: PA; SP; LA; QL); when such controls are present the prescriber must follow PA and specialty procedures and supply supporting documentation.

• Follow PA and specialty pharmacy routing for high‑cost agents listed with SP/LA
• Provide required clinical documentation to support PA requests

Confirm and satisfy utilization controls shown per product

Prior authorization, step edits, quantity limits and other utilization controls are indicated next to many formulary drugs; prescribers should confirm the required edits on the product line and submit PA or documentation as applicable.

• Confirm product‑specific ‘Requirements / Limits’ flags before prescribing
• Submit PA and required clinical information when indicated

Obtain PA and follow quantity limits listed

Formulary lines indicate when PA and quantity limits apply; prescribers must obtain PA and adhere to QL values noted for products (many adjunctive agents show PA and QL entries).

• Obtain PA for products marked ‘PA’
• Adhere to numeric QL entries (e.g., per day or per period) listed on the formulary

Check and document age‑based PA requirements

Multiple products include age‑based prior authorization rules (for example, intramuscular antipsychotic injections such as INVEGA SUSTENNA require PA for age 17 and younger); prescribers must check age‑specific PA requirements and document accordingly.

• Verify age‑based PA flags on product entries before prescribing for pediatric/adolescent patients
• Include age and clinical justification in PA submission when required

Adhere to per‑fill/unit restrictions or request exception

Some products have special fill/unit restrictions (examples: NARCAN: 2 sprays per fill; OPVEE: 2 units per fill; ZIMHI: 1 ml per fill); prescribers and pharmacists must follow these per‑fill limits or request an exception via PA with justification.

• Adhere to per‑fill unit limits noted on the formulary line
• Request PA with medical necessity documentation to exceed per‑fill limits

Obtain PA for adjunctive agents with PA/QL flags

The formulary repeatedly notes PA and quantity limits for many adjunctive agents; prescribers must obtain PA and provide required documentation for these listed products when coverage is conditioned on PA/QL.

• Submit PA and supporting clinical information for adjunctive agents marked ‘PA’
• Ensure QL values are observed or request an exception with justification

Include age and dosing schedule for long‑acting injectables PA

Several long‑acting injectable antipsychotics have age‑based PA (e.g., INVEGA TRINZA and INVEGA SUSTENNA require PA for age 17 and younger) and specific dose‑per‑period quantity limits; prescribers must include age and dosing schedule in PA submissions.

• Include patient age and requested dosing interval in the PA documentation
• Comply with the QL dosing schedule shown (dose per 28/63/135 days as applicable)

PA required for many adjunctive agents — risk of denial if not obtained

Prior authorization and quantity limits apply to many listed adjunctive agents (examples: PAXIL CR entries and perphenazine show PA and age‑specific limits); failure to obtain PA may result in non‑coverage or claim denial.

• Obtain PA when PA is indicated on the formulary line
• Document adherence to age‑ or strength‑specific limits to avoid denial

Route SP/LA products through specialty channels and obtain PA

Some products are designated specialty (SP), limited access (LA), or require site/provider restrictions (e.g., sodium oxybate, SPRAVATO, WAKIX, XYREM/XYWAV); prescribers must route prescriptions to the appropriate specialty channel and obtain PA and site approvals when required.

• Refer SP/LA items to participating specialty pharmacies per plan guidance
• Obtain PA and comply with any site or provider limitations listed

Document trials for step therapy or request PA to override

Certain products have step therapy or supported trial requirements noted (for example, PLEGRIDY shows ST and many items are marked ST); prescribers must document completed trials or request PA to override step edits.

• Document completed trials of required agents to satisfy ST
• If unable to complete required trials, submit PA with clinical rationale to bypass ST

Review and comply with utilization controls to secure coverage

Utilization controls (PA, ST, SP, CED, QL, LA) are present across the formulary and determine coverage; prescribers must meet the listed requirements and submit necessary documentation to obtain authorization and coverage.

• Review the Requirements / Limits column for each product before prescribing
• Provide required clinical documentation and obtain PA where indicated

Follow the QL formats shown or request exception

Quantity limit examples on the formulary include formats such as QL (1 per 1 day), QL (1 per 28 days), QL (30 per 365 days), and product‑specific numeric limits; prescribers must follow these QL formats or request an exception with medical necessity documentation.

• Observe the QL timeframes and numeric limits specified per product
• Submit PA and medical necessity documentation to exceed QLs

Obtain PA and include required supporting info to avoid denials

Many formulary drugs require PA and/or have quantity limits and specialty requirements; when PA is indicated prescribers must obtain authorization prior to dispensing and include requested supporting information to avoid denied claims.

• Obtain PA prior to dispensing when ‘PA’ is listed
• Include all requested supporting documentation (e.g., labs, prior therapy, medical necessity) in PA submission

Coordinate PA and specialty distribution for high‑cost items

Several high‑cost specialty items require prior authorization plus specialty distribution and limits (examples: UPTRAVI, CABLIVI); prescribers should confirm SP/LA flags and coordinate specialty dispensing and PA requirements.

• Confirm SP/LA designation on product entry and route to the designated specialty pharmacy
• Obtain PA and comply with any specialty dosing or supply limits

Follow PA/ST/QL/SP controls as summarized on formulary

Summary: many drugs in this formulary require prior authorization, step therapy, and/or quantity limits; prescribers must follow the use‑case specific processes (PA submissions, clinical documentation, specialty routing) to obtain coverage.

• Check each product’s Requirements / Limits before prescribing
• Submit PA with clinical documentation and request QL or non‑formulary exceptions as needed

Utilization controls require compliance to secure coverage

Overall utilization controls across the formulary require prescribers to obtain prior authorization, complete step therapy trials, or adhere to quantity limits and specialty routing as shown; failure to meet these controls can prevent coverage.

• Meet PA, ST, QL, and SP requirements as listed per product
• Document clinical rationale in the PA when requesting exceptions