CurrentAvMedPolicy N/A

Crinone (progesterone vaginal gel) prior authorization / step-edit

This form governs prior authorization and step-edit requirements for Crinone (progesterone vaginal gel) prescriptions for AvMed members; it specifies required documentation, clinical criteria for approval, and administrative submission instructions for providers.

Policy Summary

PayerAvMed

PolicyCrinone (progesterone vaginal gel) prior authorization / step-edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a signed prior authorization request to 1-305-671-0200 with required clinical documentation; incomplete forms may delay or deny authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3approval clinical pathways offered on form

12 weeksauthorization duration for pregnancy indication

6 dosesauthorization duration for secondary physiologic amenorrhea (4%)

Specialty Pharmacymedication provided by

Coverage Criteria

Clinical approval criteria

Covered when ALL of the following are met (select the applicable clinical pathway and provide supporting documentation):

Approval pathways

Pregnancy indication: Member is pregnant and requires the use of Crinone until placental autonomy; submit results of a positive pregnancy test.Authorization: 12 weeks
Secondary physiologic amenorrhea - initial: Member has secondary physiologic amenorrhea.Authorization: 6 doses of Crinone 4%
Secondary physiologic amenorrhea - after 4% failure:

Policy Summary

PayerAvMed

PolicyCrinone (progesterone vaginal gel) prior authorization / step-edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a signed prior authorization request to 1-305-671-0200 with required clinical documentation; incomplete forms may delay or deny authorization.

SourceLink

On This Page

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Member has secondary physiologic amenorrhea and was unresponsive to 6 doses of Crinone 4%.

Authorization: 6 doses of Crinone 8%

Infertility uses are EXCLUDED. Requests that indicate Crinone is being prescribed for infertility treatment will not meet coverage criteria and should not be submitted for authorization under this form.

Coding and Authorization Durations

ICD-10ICD-10

No codes listed

Authorization durations

PregnancyAuthorization duration: 12 weeks (submit positive pregnancy test).

Secondary physiologic amenorrhea (Crinone 4%)Authorization duration: 6 doses of Crinone 4%.

Escalation if unresponsiveIf unresponsive to 6 doses of Crinone 4%, authorization may be provided for 6 doses of Crinone 8%.

Provider Submission & Documentation Requirements

Prior Authorization

Submission and signature requirement

Prior authorization requests must be faxed to 1-305-671-0200. The prescribing physician must sign and clearly print their name on the request (preprinted stamps are not valid). All other information may be completed by office staff. Ensure phone and fax numbers are included and correct — no additional phone calls will be necessary if the form is complete and legible.

Fax: 1-305-671-0200
Prescriber signature required (hand-signed; no preprinted stamps)
Include prescriber printed name and date

Denial Risk

Incomplete or insufficient documentation

Authorization may be delayed or denied if the form is incomplete, incorrect, illegible, or missing required documentation. All clinical criteria checked must be supported by documentation (lab results, diagnostics, chart notes).

Incomplete/illegible forms can delay authorization
Missing supporting documentation (labs, diagnostics, chart notes) may result in denial
Ensure all required fields are completed before faxing

Documentation Required

Required submission information

Include complete member and prescriber information and drug details on the request. The prescriber must sign and print their name (no preprinted stamps). Provide contact phone and fax numbers and the prescriber’s DEA or NPI. Provide drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, and date.

Member name and AvMed ID (member number)
Member date of birth
Prescriber name, hand signature, date, office contact name
Office phone and fax numbers
Prescriber DEA or NPI number
Drug form/strength, dosing schedule, length of therapy, diagnosis, ICD code (if applicable), weight, date

Step Therapy

Step-edit verification

Step-edit verification: previous therapies will be confirmed via pharmacy paid claims or submitted chart notes. Note that samples do not satisfy step-edit or preauthorization requirements.

Samples do not meet step-edit requirements
Provide chart notes or allow claims verification to demonstrate prior therapy

Background

Progesterone vaginal gel (Crinone) is used as luteal support in pregnancy until placental autonomy; when requested for this indication the form requires submission of a positive pregnancy test and, if approved, authorization is provided for 12 weeks.

Crinone is also covered for management of secondary physiologic amenorrhea. For initial treatment with the 4% formulation, authorization is for 6 doses. If the member is unresponsive to 6 doses of Crinone 4%, the policy allows escalation to the 8% strength with authorization for an additional 6 doses.

All clinical pathways require supporting documentation (lab results, diagnostics, or chart notes). The medication is supplied via specialty pharmacy (PropriumRx), and use of samples does not satisfy step-edit requirements.

Definitions

Placental autonomy — definition

Placental autonomyDefined in this policy as the point at which the placenta adequately supports the pregnancy and exogenous progesterone (Crinone) is no longer required.

Initial Therapy Criteria

Initial therapy

Initial authorization rules by indication

Pregnancy indication: Member is pregnant and requires use of Crinone until placental autonomy; submit positive pregnancy test.12 weeks

Secondary physiologic amenorrhea - initial: Member has secondary physiologic amenorrhea; authorization for Crinone 4%.6 doses

Step Therapy Rules

Step	Failure criterion	Authorization if criteria met
1	Unresponsive to 6 doses of Crinone 4%	Authorization may be provided for 6 doses of Crinone 8%

Quantity Limits

Crinone 4%

Crinone 4% quantity limit6 doses per authorization/course.

Crinone 8%

Crinone 8% quantity limit6 doses per authorization/course (used when unresponsive to 4% after 6 doses).

Crinone for pregnancy

Crinone for pregnancy durationAuthorization duration: 12 weeks (requires submission of positive pregnancy test).

Site of Care / Dispensing

Billing Rule

Specialty pharmacy dispensing (PropriumRx)

This medication is provided through the specialty pharmacy PropriumRx; route orders and prior authorization accordingly.

Medication being provided by Specialty Pharmacy - PropriumRx