CurrentAvMedPolicy N/A

Prior authorization form for Auvi-Q (epinephrine auto-injector)

Form and clinical criteria governing pharmacy prior authorization and step-edit requests for Auvi-Q (epinephrine injection, 0.1 mg auto-injector) for AvMed members; applies to prescribers requesting coverage. Affects patients who require epinephrine auto-injector therapy and prescribers completing prior authorization.

Policy Summary

PayerAvMed

PolicyPrior authorization form for Auvi-Q (epinephrine auto-injector)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign and print name on the request and fax completed form to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moInitial authorization duration

7.5–15 kgRequired member weight

1Prescriber signature required

1-305-671-0200Fax to submit

Coverage Criteria

Initial Authorization Criteria

Covered when ALL of the following are met

Weight eligibility: Member must weigh 7.5 to 15 kg (16.5 to 33 lbs); chart notes documenting current weight must be submitted.7.5 to 15 kg

Authorization approved for 12 months then reauthorization required to reassess weight

Documentation: All documentation supporting each checked clinical criterion (lab results, diagnostics, chart notes) must be provided or request may be denied.

Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Prescriber attestation: Prescribing physician must sign and clearly print name on the request (preprinted stamps not valid).

Fax completed request to 1-305-671-0200.

Policy Summary

PayerAvMed

PolicyPrior authorization form for Auvi-Q (epinephrine auto-injector)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign and print name on the request and fax completed form to 1-305-671-0200.

SourceLink

On This Page

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Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Sample administration alone is not sufficient to satisfy the step-edit requirement for Auvi‑Q prior authorization; previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Coding

ICD-10 (member to provide if applicable)ICD-10

ICD Code, if applicable (field provided on form)

Member weight for 0.1 mg Auvi-Q

Required weight range7.5 to 15 kg (16.5 to 33 lbs)

Documentation requiredChart notes documenting current weight must be submitted for verification

PurposeWeight eligibility specifically for Auvi-Q 0.1 mg auto-injector

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Submission Required

The prescribing provider must sign and clearly print their name on the request (preprinted stamps are not valid). Fax the completed request and all supporting documentation to the prior authorization fax number: 1-305-671-0200. Include current phone and fax numbers on the form to avoid unnecessary delays.

Fax: 1-305-671-0200
Prescriber signature and printed name required (no preprinted stamps)

Step Therapy

Step-Edit / Prior Therapy Verification

Use of manufacturer or office samples to start therapy does not satisfy step-edit or prior authorization requirements. Prior therapies may be verified via pharmacy paid claims or submitted chart notes; document prior treatment attempts when applicable.

Samples do not meet step-edit/preauthorization criteria
Previous therapies may be verified through pharmacy paid claims or chart notes

Documentation Required

Required Clinical Documentation

Submit chart notes documenting the member's current weight and all clinical documentation that supports the requested drug (e.g., diagnostics, lab results, progress notes). Requests may be denied if supporting documentation for any checked clinical criteria is not provided.

Chart notes documenting current weight (required)
All documentation supporting each checked clinical criterion (labs, diagnostics, notes)

Denial Risk

Incomplete or Missing Information May Delay/Prevent Authorization

Authorizations may be delayed or denied if the form is incomplete, incorrect, or illegible, or if required supporting documentation is missing. Ensure weight, diagnosis/ICD code, drug form/strength, dosing schedule, length of therapy, and date are completed on the form.

Complete fields: drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight, date
Incomplete/illegible submissions risk delay or denial

Background

Auvi‑Q (epinephrine auto‑injector) is indicated for the emergency treatment of severe allergic reactions (anaphylaxis) when immediate epinephrine administration is required. The form emphasizes weight‑based eligibility for the 0.1 mg device and documents that authorization is granted for 12 months with reauthorization required to reassess patient weight. Chart notes documenting current weight must be submitted to support the request.

Definitions

Initial Authorization

Initial approval period12 months

Reauthorization requirementReauthorization required after 12 months to reassess patient weight

Relation to coverage criteriaAuthorization tied to weight-based eligibility (7.5–15 kg); ongoing documentation of weight needed at reauthorization

Initial Therapy Criteria

Initial Authorization — Auvi-Q 0.1 mg

Initial authorization criteria for Auvi-Q 0.1 mg

Weight requirement: Member must weigh 7.5 to 15 kg (16.5 to 33 lbs); submit chart notes documenting current weight.7.5 to 15 kg

Continuation / Reauthorization Criteria

Reauthorization

Reauthorization rules

Reauthorization: Authorization will be approved for 12 months; reauthorization is required to reassess patient weight.12 months

Step Therapy / Prior Authorization Rules

Step	Requirement	Notes
1	Use of samples to initiate therapy does not satisfy step-edit/preauthorization requirements.	Previous therapies may be verified through pharmacy paid claims or submitted chart notes.