CurrentAvMedPolicy N/A

ACA Copay Waiver for Breast Cancer Prevention Therapy

Form and policy governing prior authorization/step-edit requests for a zero-dollar copay waiver for medications used for primary prevention of breast cancer for AvMed members; applies to prescribers requesting this waiver.

Policy Summary

PayerAvMed

PolicyACA Copay Waiver for Breast Cancer Prevention Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization/step-edit request form with the prescribing physician's original signature and supporting documentation to AvMed (fax 1-305-671-0200).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3required clinical checklist items

≥35minimum member age for approval

zero-dollarcost share if criteria met

Coverage Criteria

Approval criteria

Coverage at zero-dollar cost share will be approved based on ALL the following criteria:

Zero-dollar copay waiver approval criteria: Member is >= 35 years of age; Member is utilizing the requested medication for primary prevention of breast cancer because the member is at high risk; Member does NOT have a prior diagnosis of breast cancer.all three criteria must be met

Supporting documentation (lab results, diagnostics, and/or chart notes) must be provided for each checked item.

Members with a prior diagnosis of breast cancer are excluded from the zero-dollar copay waiver for primary prevention therapy. The form requires that all checked clinical criteria be met for approval, including confirmation that the member does NOT have a prior diagnosis of breast cancer; supporting documentation (lab results, diagnostics, and/or chart notes) must be provided for each checked item.

Coding and Age Requirements

Requested diagnosis codesICD-10

ICD code, if applicable

field on form for relevant diagnosis code

Policy Summary

PayerAvMed

PolicyACA Copay Waiver for Breast Cancer Prevention Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization/step-edit request form with the prescribing physician's original signature and supporting documentation to AvMed (fax 1-305-671-0200).

SourceLink

On This Page

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Member age

Minimum age for approval>= 35 years

Source sectionClinical criteria: Member is >= 35 years of age

Related requirementAll clinical criteria must be met for approval

Initial Therapy Approval

Initial therapy approval

Initial approval conditions

Initial approval: Member is >= 35 years; medication used for primary prevention because member is high risk; no prior breast cancer diagnosis; prescriber submits required form with original signature and provides supporting documentation (lab results, diagnostics, and/or chart notes) for each checked criterion.all

Authorization may be delayed or denied if the form is incomplete, illegible, or supporting documentation is not provided.

Provider Actions and Submission Requirements

Prior Authorization

Submission requirements

A prior authorization/step-edit request form must be completed and faxed to AvMed at 1-305-671-0200. The prescribing physician must hand-sign and clearly print their name on the request (preprinted stamps are not valid). All required information (including accurate phone and fax numbers) should be provided to avoid delays; no additional phone calls will be necessary if the form is complete and correct. If the information provided is incomplete, incorrect, or illegible, the authorization process may be delayed or the request may be denied.

Fax: 1-305-671-0200
Form: Pharmacy Prior Authorization/Step-Edit Request
Note: No extra phone calls required if form is complete and correct

Step Therapy

Step-edit form

This is a prior authorization/step-edit request form for pharmacy benefit review. The form itself implements the step-edit/prior authorization process; no additional step-therapy logic beyond what is on the form is specified.

Form name printed on form: PHARMACY PRIOR AUTHORIZATION/STEP-EDIT REQUEST
Drug requested example on form: ACA Copay Waiver for Breast Cancer Prevention Therapy

Documentation Required

Required form fields and supporting documentation

Required form fields and supporting documentation must be provided with the request. The prescribing physician’s signature must be hand-signed and include a printed name (preprinted stamps are not acceptable). Member and prescriber information, drug information, dosing schedule, length of therapy, diagnosis (with ICD code if applicable), weight, and date must be completed. Clinical criteria boxes must be checked as applicable and supporting documentation (lab results, diagnostics, chart notes) must be included for each checked item. Failure to include required fields or supporting documentation may result in delay or denial.

Prescriber signature: hand-signed and printed name required (preprinted stamps invalid)
Member information: name, AvMed ID#, DOB
Prescriber information: name, DEA or NPI#, office contact, fax number, date
Drug information: drug, form/strength, dosing schedule, length of therapy
Diagnosis and ICD code (if applicable); weight and date
Clinical criteria: all applicable boxes must be checked and supported with documentation (labs, diagnostics, chart notes)

Denial Risk

Incomplete or insufficient documentation

If the form is incomplete, incorrect, or illegible, or if supporting documentation is missing, the authorization may be delayed or the request may be denied. Provide complete clinical documentation to support each checked clinical criterion to prevent denial.

Incomplete/illegible forms can delay authorization
Missing supporting documentation (labs, diagnostics, chart notes) may result in denial
Ensure phone and fax numbers are correct on the form

Background

This form is intended to authorize zero-dollar cost-share coverage for medications used for primary prevention of breast cancer in high-risk members. Approval at zero-dollar cost share is contingent on meeting all listed clinical criteria and submitting supporting documentation (lab results, diagnostics, and/or chart notes) for each checked criterion.

Definitions

Primary prevention of breast cancer

DefinitionUsing medication to reduce the risk of developing breast cancer in a member who does not have a prior diagnosis (primary prevention of breast cancer)

Coverage intentForm authorizes zero-dollar cost-share coverage for medications used for primary prevention in high-risk members

ExclusionMember must NOT have a prior diagnosis of breast cancer to qualify

Step Therapy

Step	Requirement / Notes
1	This form is a prior authorization/step-edit request for the ACA Copay Waiver for Breast Cancer Prevention Therapy; the form itself does not specify a step sequence or required prior medication failures. Providers must complete and sign the form and fax to AvMed at 1-305-671-0200. Authorization may be delayed if the form is incomplete, incorrect, or illegible.