Obtain prior authorization using AvMed drug authorization form

Prescriber must submit a completed drug authorization request form and supporting clinical documentation (lab values, prescription history, statement of medical necessity or other pertinent information) to AvMed via fax to 1305-671-0200; urgent PA decisions typically within 24 hours and standard decisions within 1–3 business days.

• Use the pharmacy drug authorization request form available at https://www.avmed.org/prescriptions/ or https://www.avmed.org/forms/provider.
• Include labs, prescription history, and statement of medical necessity as needed to satisfy coverage guidelines.

Submit medical necessity statement for QL or non‑formulary requests

If a prescription exceeds a listed quantity limit or a non-formulary medication is requested, the prescriber must submit a statement of medical necessity and supporting documentation through the prior authorization process to request an exception.

• For QL exceptions: provide a statement of medical necessity and request prior authorization per the Prior Authorization Process.
• For non‑formulary requests: provide medical records/prescription claims history showing medical necessity, contraindications to all formulary alternatives, or therapeutic failure of adequate trials of formulary alternatives.

Provide documentation for step therapy / CED exceptions

Step therapy and Clinically Equivalent Drug (CED) rules require clinical documentation and will have prior authorization when applicable; medications labeled CED on the formulary will also require PA.

• If a member cannot use required first- or second-line therapy for medical reasons, prescriber should request prior authorization with supporting documentation.
• CED-labeled medications require submission of clinical documentation establishing medical necessity over comparable formulary alternatives.

Member-initiated prior authorization permitted

Members may initiate a prior authorization by contacting AvMed Member Engagement (number on member ID card) or via the prescriptions section of AvMed's website; the member should provide prescriber contact information and pertinent details to the representative.

• Members can also start the process by logging into https://www.avmed.org/prescriptions/#list-of-covered-drugs and clicking the 'Prescriptions' link.

Follow PA/QL/ST/SP utilization management flags on formulary entries

Prior Authorization (PA), Quantity Limit (QL), Step Therapy (ST) and Specialty (SP) flags on formulary entries require adherence to those controls; PA must be obtained before coverage for drugs marked PA.

• Check each formulary line for requirement flags (PA, QL, ST, SP, LA) before prescribing or dispensing.
• Drugs marked PA will not be covered unless prior authorization is approved.

Obtain PA when formulary entry shows PA + QL (examples provided)

Some drugs require both prior authorization and specific quantity limits per fill (example: DIFICID oral suspension requires PA and is limited to 100 mL per fill; fidaxomicin requires PA and is limited to 20 tablets per fill).

• Verify both PA requirement and QL value in the formulary entry and submit PA request citing the specific formulation and quantity limit.
• Include prescription details that match the QL (e.g., mL per fill or tablets per fill) when requesting authorization.

Request PA and use specialty pharmacy for oncology/limited‑distribution products

High‑cost oncology and immunosuppressant therapies are frequently flagged PA and SP, and may also have Limited Availability (LA); obtain PA and arrange specialty pharmacy dispensing when indicated.

• Examples include many Tier 5 antineoplastic agents listed with PA; SP; LA and specified QL values (e.g., IBRANCE, VITRAKVI, XALKORI).
• Contact AvMed/Customer Service for LA details and specialty pharmacy routing.

Adhere to per‑product PA/SP/QL/LA controls shown on formulary entries

Many formulary entries include PA, SP, QL and sometimes LA controls; prescribers must follow the per‑product Requirements / Limits shown on the formulary and obtain authorization or use specialty channels as required.

• Confirm per‑product controls (PA/SP/LA/QL) prior to prescribing; examples in the formulary show these flags across many entries.
• Where SP is indicated, dispense through a participating specialty pharmacy as required.

Check utilization control flags (PA / SP / LA / QL / ST) on each drug line

Formulary entries use standardized flags (PA, SP, LA, QL, ST) — verify the annotation on each drug line and follow the indicated prior authorization, specialty pharmacy, step therapy, or quantity‑limit procedures.

• These flags determine whether PA, specialty dispensing, limited distribution, or step therapy are required before coverage.
• Use the formulary legend at the beginning of the table to interpret abbreviations if needed.

Obtain PA or follow utilization controls shown in Requirements / Limits

Many products across the formulary require some combination of PA, QL, ST, SP or LA — prescribers must review the Requirements / Limits column and request authorization or follow step therapy pathways as specified.

• Examples in the listing include age‑based PA and QL values; adhere strictly to the entry details when requesting exceptions.
• If symbols/abbreviations are unclear, refer to the table legend at the start of the formulary.

Submit PA for specialty/ER products that list PA and QL

Certain extended‑release and specialty injectable products have explicit quantity limits and may require prior authorization (examples: SUBLOCADE, XTAMPZA ER — check each formulary line for PA and stated QL).

• XTAMPZA ER is shown with QL (6 per 1 day) and PA where indicated; confirm product‑specific rules before prescribing.
• For extended‑release or ER specialty products, include formulation details in PA requests.

Follow formulary entry PA and age‑based QL rules (e.g., ARISTADA)

Numerous formulary entries indicate PA requirements and quantity limits for specific products and age groups (e.g., ARISTADA injectables require PA for Age ≤17 and list QL values); prescribers must follow those entry‑specific authorization rules.

• When age‑based PA is shown, include the patient age and any supporting pediatric/age‑specific documentation in the PA request.
• Match the requested dose/presentation to the formulary line when submitting the authorization.

Document step therapy trials and follow LA instructions for specialty products

Specialty products may also be subject to step therapy and limited access controls; where ST or LA appear (e.g., HETLIOZ, LUMRYZ, SPRAVATO), prescribers must document prior trials or obtain PA per the formulary requirements.

• If step therapy applies, document trials of required agents or provide medical justification in the PA request.
• For LA products, contact AvMed/Customer Service for dispensing location details and PA instructions.

Consult per‑drug Requirements / Limits and submit PA/documentation as listed

The formulary frequently annotates entries with PA, QL, SP, LA and ST — prescribers must consult the Requirements / Limits column for each drug and submit prior authorizations or documentation when those controls are present.

• Provide clinical rationale and required supporting materials per the Prior Authorization Process when controls are present.
• Do not assume coverage if a formulary entry includes a PA or QL flag.

Include age and age‑specific justification for PA when entry lists age restrictions

Certain products include age‑based prior authorization restrictions (e.g., PA for Age ≤17); prescribers must include patient age and age‑specific justification when requesting authorization.

• Examples: ARISTADA and multiple injectable products list PA for specific age ranges — include age and relevant clinical notes in PA submission.

Request PA and coordinate specialty pharmacy for biologics/dermatologic biologics

Multiple high‑cost biologic and dermatologic agents are listed with PA, often SP and QL (examples: HYMPAVZI PEN, MULPLETA, REPATHA products); prescribers must request PA and arrange specialty pharmacy dispensing where indicated.

• When QL is specified, include the requested quantity and timeframe in the PA submission.
• For SP‑flagged products, ensure prescription is routed to a participating specialty pharmacy per AvMed guidance.

Obtain PA for formulary topical products marked PA (examples provided)

Topical antifungals and antivirals may require prior authorization (examples: LULICONAZOLE, SULCONAZOLE TOPICAL SOLUTION, tavaborole are listed as PA); submit PA per the Prior Authorization Process for these entries.

• Penciclovir and acyclovir topical entries show PA and QL (e.g., QL 5 per 30 days) — include quantity details in PA requests.

Submit PA and follow SP/LA/Q L rules for high‑tier specialty products (EMPAVELI example)

Some specialty/high‑tier products (e.g., EMPAVELI) are marked PA; SP; LA and include specific QL values (EMPAVELI QL 160 per 28 days); prescribers must request PA and follow specialty/limited distribution procedures.

• Include the exact product presentation and requested quantity (per the QL) in the PA submission.
• For LA products, contact AvMed for dispensing instructions and specialty pharmacy routing.

Request QL exceptions via PA when prescribed quantity exceeds formulary QL

Some formulary entries list specific QL values (e.g., penciclovir PA; QL 5 per 30 days); prescribers must request a QL exception via PA with a medical necessity justification if the prescribed quantity exceeds the stated limit.

• When requesting a QL exception, state the quantity requested, clinical rationale, and duration of therapy.

Include device model and clinical data when requesting PA for CGM devices/sensors

Continuous glucose monitoring devices and supplies are designated CGM and require prior authorization and have quantity limits (e.g., DEXCOM G6 receiver: PA; CGM; QL 1 per 365 days; sensors/transmitters have specific QLs); include device type and necessary clinical data in PA requests.

• Dexcom examples: G6 receiver QL 1 per 365 days; G6 sensor QL 3 per 30 days; G7 sensor QL 2 per 30 days — include device model in the PA.
• Provide diabetes management data or clinical justification supporting CGM coverage.

Honor insulin QLs (100 units/30 days common) and obtain PA when required

Insulin products and insulin delivery devices generally have quantity limits (commonly 100 units per 30 days) and some formulations require prior authorization; confirm QL on the formulary and include unit limits in the PA or prescription.

• Many insulin pens and vials are listed with a 100 units per 30 days QL; certain concentrated pens may require PA in addition to the QL.
• For pump supplies and starter kits, note the specified QL (e.g., intro kits 1 per 720 days; pods 10 per 30 days).

Submit PA with dose/quantity details for GLP‑1 and related agents (MOUNJARO/OZEMPIC/RYBELSUS examples)

For select specialty diabetes and obesity medications, PA and QL requirements are specified (examples: MOUNJARO: PA; QL 2 per 28 days; OZEMPIC oral tablet 1.5 mg: PA; QL 30 per 365 days; RYBELSUS formulations list PA and product‑specific QLs).

• Include product strength, dosing frequency and requested quantity in the PA submission for GLP‑1 and related agents.
• Check each formulation's QL timeframe (per 28 days vs per 365 days) when requesting authorization.

Request PA and route biologics to specialty pharmacy; include prior therapy history

Many biologics and other specialty agents require prior authorization and are dispensed via specialty pharmacy with quantity limits (examples: ENTYVIO PEN, CIMZIA, SKYRIZI; RELISTOR subcutaneous products list PA and QL values).

• When prescribing biologics, include indication, prior therapies tried, and requested dosing schedule in the PA.
• Route prescriptions for SP‑flagged products to a participating specialty pharmacy per AvMed instructions.

Include clinical/lab data when seeking PA for biotechnology and rheumatology biologics

Many biotechnology products list PA and specialty pharmacy requirements and often include quantity limits (per day, per 28/63/365 days); prescribers must follow the entry‑specific PA/QL/SP rules for these agents.

• Examples include erythropoiesis‑stimulating agents and rheumatology biologics with PA; SP; QL (values vary by product).
• Provide necessary lab data, diagnoses, and prior medication trials in PA submissions for biotechnology drugs.

Comply with combined utilization controls (PA / SP / ST / QL) for specialty/biologic drugs

Utilization controls across many specialty and biologic agents include PA, SP, ST and QL flags; prescribers must check and comply with each control type listed for the medication.

• Step therapy (ST) may require documented trials of specified agents prior to coverage of the requested drug.
• Quantity limits must be respected or justified via a QL exception request through PA.

Request PA and include ophthalmology documentation for ophthalmic specialty drugs (CYSTADROPS/OXERVATE examples)

Select ophthalmic specialty drugs require PA and specialty pharmacy handling and specify QLs (e.g., CYSTADROPS PA; SP; QL 20 per 28 days; OXERVATE PA; SP; QL 56 per 720 days); include ophthalmic formulation and quantity in the PA request.

• For ocular biologics and specialty drops, attach ophthalmology notes and prior treatments to the PA.
• Confirm the QL timeframe (per 28 days vs per 720 days) and request exceptions only when clinically justified.

Submit PA with clinical evidence for pulmonary/biologic therapies and follow SP/LA rules

Multiple specialty pulmonary and systemic biologic therapies (e.g., ADEMPAS, NUCALA, ORKAMBI, PULMOZYME) are listed with PA; SP; LA and QL controls — prescribers must request prior authorization, coordinate specialty dispensing, and provide required clinical documentation.

• Include disease‑specific objective data (e.g., pulmonary function tests) and prior treatment history in PA submissions for pulmonary biologics.
• For LA products, confirm dispensing source and follow specialty pharmacy routing instructions.

Obtain PA for AUVI‑Q and check PA/QL for epinephrine auto‑injectors

Some auto‑injector products have formulary tier assignments and may require prior authorization (AUVI‑Q is listed as PA); verify the auto‑injector line and obtain PA where the formulary requires it.

• AUVI‑Q injection auto‑injector 0.1 mg/0.1 mL is explicitly listed with Requirements = PA — submit PA accordingly.
• Epinephrine auto‑injectors have tiering and quantity guidance; confirm QL and PA on the formulary line before dispensing.