CurrentAvMedPolicy N/A

Prior authorization form and coverage criteria for Duavee (conjugated estrogens/bazedoxifene)

Form and criteria used by AvMed to request pharmacy prior authorization or step-edit approval for Duavee; affects prescribers and members seeking coverage for this medication.

Policy Summary

PayerAvMed

PolicyPrior authorization form and coverage criteria for Duavee (conjugated estrogens/bazedoxifene)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed prior authorization form with supporting documentation showing failure of two prior agents (≥30 days each).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1drug covered by this form

1 tabrecommended dosage listed

30drequired trial duration

2prior agents required to fail

Coverage Criteria

Initial approval criteria

Approved when ALL of the following are met:

Indication: Member is being prescribed medication for ONE of the following indications: moderate to severe vasomotor menopausal symptoms OR member is at significant risk of osteoporosis.

Documentation must support the indicated diagnosis; all documentation (labs, diagnostics, chart notes) must be provided or request may be denied.

Prior therapy: Member has tried and failed 30 days of therapy with TWO of the following medications: alendronate tablets; generic estradiol transdermal patches; Premphase tablets; estradiol tablets; Premarin vaginal cream; Prempro tablets; generic estradiol vaginal cream; Premarin tablets; raloxifene tablets.2 agents, each ≥30 days

Previous therapies will be verified through pharmacy paid claims or submitted chart notes. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Policy Summary

PayerAvMed

PolicyPrior authorization form and coverage criteria for Duavee (conjugated estrogens/bazedoxifene)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed prior authorization form with supporting documentation showing failure of two prior agents (≥30 days each).

SourceLink

On This Page

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Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The prescriber must complete and sign the pharmacy prior authorization request form and fax it to 1-305-671-0200. Requests may be delayed or denied if the form is incomplete, illegible, unsigned, or missing required contact information (prescriber name, signature, phone, fax, DEA or NPI).

Form must be signed by prescribing physician (preprinted stamps not valid).
Include prescriber contact details: office contact name, phone and fax number, DEA or NPI.

Step Therapy

Step Therapy Requirement

Step therapy (step-edit) applies. Member must have tried and failed 30 days of therapy with TWO listed agents prior to approval. Use of samples to initiate therapy does not satisfy step-edit requirements. Previous therapies will be verified through pharmacy paid claims or submitted chart notes; if a medication is non-formulary, documentation of medical necessity is required.

Required trial: 30 days on TWO agents from the listed options (e.g., alendronate, generic estradiol transdermal patches, Premphase, estradiol tablets, Premarin vaginal cream, Prempro, generic estradiol vaginal cream, Premarin tablets, raloxifene).
If a listed drug is non-formulary for the member's plan, include medical necessity documentation.

Documentation Required

Required Form Fields and Supporting Documentation

To process the request, include complete prescriber identification, member details, drug name/formulation, diagnosis and ICD code (if applicable), recommended dosing schedule and length of therapy, and weight/date as indicated on the form. Attach supporting documentation for all criteria checked (lab results, diagnostics, chart notes) to substantiate the diagnosis and prior therapy trials.

Prescriber identification: name, signature, DEA or NPI, office contact, phone and fax.
Member details: full name, AvMed member number, date of birth.
Drug information: drug requested, form/strength, dosing schedule, length of therapy, recommended dosage.
Clinical documentation: diagnosis, ICD code (if applicable), weight, date, and supporting labs/notes.

Denial Risk

Incomplete or Illegible Requests

Incomplete, incorrect, or illegible requests — including unsigned forms or missing contact information — may delay or result in denial of authorization.

Preprinted signature stamps are not valid — must be hand-signed by the prescribing physician.
Ensure all required fields on the form are completed to avoid processing delays.

Denial Risk

Missing Supporting Documentation

Requests lacking required supporting documentation (e.g., lab results, diagnostics, chart notes, or evidence of prior 30-day trials on two listed agents) may be denied.

Provide copies of relevant lab results, diagnostic reports, and chart notes that verify diagnosis and prior therapy attempts.
If prior therapy was obtained outside of pharmacy claims, submit chart documentation showing dates and durations of trials.

Initial Therapy Criteria

Initial therapy requirements — initial approval requires meeting indication and step-therapy requirements

Initial approval requires meeting indication and step-therapy requirements.

Indication: Patient has either moderate to severe vasomotor menopausal symptoms or is at significant risk of osteoporosis.

Documentation must support the indicated diagnosis.

Step therapy failure: Patient has failed 30 days of therapy with two listed agents from the specified list.2 agents, each ≥30 days

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

OpenPayer

Prior authorization form and coverage criteria for Duavee (conjugated estrogens/bazedoxifene)

Coverage Criteria

Coding and Trial Requirements

Provider Actions and Documentation Requirements

Background

Definitions

Initial Therapy Criteria

Step Therapy and Prior Trials

Quantity Limits