CurrentAvMedPolicy N/A

Mytesi (crofelemer) prior authorization form

A pharmacy prior authorization/step-edit request form for Mytesi (crofelemer) specifying required member/prescriber information and clinical criteria that must all be met for approval. It documents age, diagnosis, HIV status on ART, diarrhea type, and prior trial of specified antidiarrheal agents.

Policy Summary

PayerAvMed

PolicyMytesi (crofelemer) prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the prior authorization/step-edit request form and fax it to 1-305-671-0200; incomplete, incorrect, or illegible information may delay authorization.

SourceLink

POLICY UPDATE CHANGES

No material changes — policy content reflects an authorization form and approval criteria without recent substantive updates.

4Required approval criteria lines

Coverage Summary

Mytesi (crofelemer) is covered with criteria: approved for adults ≥ 18 years who have non-infectious diarrhea associated with HIV/AIDS while on antiretroviral therapy, and who have tried at least one listed antidiarrheal agent (loperamide or diphenoxylate/atropine). Note that drug samples do not satisfy the prior therapy/step-edit requirement.

Approval Criteria for Mytesi (crofelemer)

Provider Actions & Submission Requirements

Prior Authorization

Obtain prior authorization

Prescriber must complete and sign the prior authorization/step-edit request form and fax it to the number below. If the information provided is not complete, correct, or legible, the authorization process can be delayed.

Fax: 1-305-671-0200

Documentation Required

Support clinical criteria with documentation

Provide documentation (lab results, diagnostics, and/or chart notes) to support each checked criterion. All criteria must be met for approval. Previous therapies will be verified through pharmacy paid claims or submitted chart notes; failure to provide required documentation may result in denial.

Documentation Required

Prescriber signature requirement

The prescribing physician must sign and clearly print name on the request; preprinted stamps are not valid. All other information may be filled in by office staff.

Definitions & Background

This document is a pharmacy prior authorization/step-edit request form for crofelemer (Mytesi) for adults with non-infectious diarrhea associated with HIV on antiretroviral therapy. The form requests member and prescriber information (member name, ID, DOB, prescriber name, signature, contact phone/fax, DEA or NPI), drug information (form/strength, dosing, length of therapy, diagnosis, ICD code, weight, date), and clinical criteria to be checked and documented. The clinical criteria list age (≥ 18 years), diagnosis of HIV/AIDS on ART, non-infectious diarrhea, and prior trial of one of the specified antidiarrheal therapies (loperamide or diphenoxylate/atropine); documentation such as lab results, diagnostics, and chart notes must be provided.

Samples: drug samples used to initiate therapy do not meet step edit/preauthorization criteria and cannot be used to satisfy the prior therapy requirement.