CurrentAvMedPolicy N/A

Daybue (trofinetide) / Daybue STIX prior authorization

Prior authorization / step-edit form and criteria for Daybue (trofinetide) oral solution and Daybue STIX packets for treatment of classical/typical Rett syndrome for AvMed members; includes initial and reauthorization clinical requirements, dosing/quantity limits, and specialty pharmacy/vendor information.

Policy Summary

PayerAvMed

PolicyDaybue (trofinetide) / Daybue STIX prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the PA/step-edit request form and fax required documentation (genetic testing, baseline objective measures, weight, labs, chart notes) to 1-305-671-0200 to support authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported for this policy.

1Covered Indication (Rett syndrome)

12Authorization Duration (months)

3600 mLMax 30-day volume (oral solution)

Coverage Summary

Prior authorization / step-edit form and clinical criteria for Daybue (trofinetide) oral solution and Daybue STIX packets for treatment of classical/typical Rett syndrome are required for AvMed members. Coverage stance: covered_with_criteria. Initial authorization duration: 12 months. Reauthorization duration: 12 months. The policy includes clinical requirements for diagnosis confirmation, prescriber specialty, exclusionary findings, required baseline assessments, dosing/quantity limits, and specialty pharmacy/vendor information.