Obtain prior authorization and submit required documentation

The ordering prescriber must obtain prior authorization for certain prescription drugs. Submit the completed drug authorization request form and supporting clinical documentation by fax to 1-305-671-0200; pharmacy forms are available at https://www.avmed.org/prescriptions/ or https://www.avmed.org/forms/provider. Coverage decisions are made within 24 hours for urgent requests and within 1–3 business days for standard requests.

Allow member-initiated prior authorization requests

Members may initiate a prior authorization by contacting AvMed Member Engagement (phone number on member ID card) or by logging into AvMed's prescriptions page and following the "Prescriptions" link; the member should provide the prescriber contact information and any pertinent clinical details for the request.

Provide medical necessity documentation for exceptions, non‑formulary, and CED requests

Requests for quantity limit exceptions, non‑formulary medications, or Clinically Equivalent Drugs (CED) require medical necessity documentation from the prescriber (e.g., medical records, prescription history, statement of medical necessity, contraindications, or therapeutic failure documentation) and must follow the prior authorization process.

PA required before fill for listed drugs

Prior Authorization (PA) is required for certain drugs; approval must be obtained before dispensing or the drug may not be covered by the plan.

Comply with step therapy requirements before coverage

Step Therapy (ST) may require trying specified drugs first before covering alternative therapies; if step therapy cannot be followed, prior authorization is used to request coverage.

Check utilization management flags on formulary entries

Many formulary entries display utilization flags (PA, SP, ST, QL, ACA, LA, CED) indicating administrative controls; review product flags on the formulary line to determine prescriber actions required.

Verify PA, specialty, and quantity-limit requirements per product

Formulary lines commonly list Prior Authorization (PA), Specialty designation (SP), and Quantity Limits (QL) — verify PA and any SP/QL requirements for the specific product before prescribing.

Recognize PA, QL, and CED flags that can trigger denials

Several agents are specifically marked with PA, QL, and CED indicators; failure to follow these requirements may result in denial of coverage.

Follow PA, SP, and QL rules for adjunctive agents

Many adjunctive agents require Prior Authorization, Specialty Pharmacy processing, and Quantity Limits (and some Limited Availability); follow the formulary-listed PA/SP/QL rules when prescribing these agents.

Confirm age-based PA restrictions on formulary lines

Some products include age‑based prior authorization requirements (for example, PA for age 9 and older on specific agents); confirm age‑based PA criteria on the formulary line before prescribing for pediatric or young adult patients.

Verify product-level PA/ST/other restrictions before prescribing

Numerous products in the formulary require PA, ST, or other utilization controls (examples include XROMI, XTANDI, ZEJULA); verify the specific authorization requirement for the product being prescribed.

Adhere to posted quantity limits or request QL exception

Quantity limits are commonly applied (e.g., brivaracetam oral solution QL = 12 per 1 day); check the formulary line for the exact QL and request a quantity‑limit exception via prior authorization if the prescription exceeds the limit.

Confirm PA and specialty/limited‑access status for high‑cost agents

Many drugs require PA and may also be designated specialty (SP) or limited access (LA); confirm PA/SP/LA status for high‑cost or specialty products before initiating therapy.

Review PA and QL for migraine and adjunctive therapies

Migraine and adjunctive therapies often include PA and QL controls; review formulary entries for those products to determine documentation and quantity requirements.

Verify PA/SP/QL for listed products

Many listed products require prior authorization; some also have specialty pharmacy requirements and quantity limits — verify product‑specific PA/SP/QL before prescribing.

Arrange specialty pharmacy processing and observe per‑28‑day QLs

Some specialty products are designated SP and have per‑28‑day QLs (for example, BRIXADI and SUBLOCADE entries show SP with 28‑day limits); arrange specialty pharmacy fulfillment and observe per‑28‑day QLs where listed.

Include specific PA and QL details in authorization requests

Multiple formulary entries list PA and specific QLs (examples include naloxone injection PA; QL 4 per 1 day and other PA+QL combinations); include exact QL and PA details from the formulary when submitting authorization requests.

Follow combined ST/SP/QL/PA rules for adjunctive agents

Adjunctive agents in the table include many PA, SP, and QL examples (e.g., PLEGRIDY ST; SP; QL 1 per 28 days; PONVORY PA; SP; QL 1 per day); follow the formulary-specified mix of ST/SP/QL/PA for these agents.

Confirm age criteria for PA on applicable products

Age-based PA restrictions are frequent (e.g., PA for age 17 and younger for multiple injectable antipsychotics; PA for age 19 and older for some stimulants); confirm age criteria on the formulary prior to prescribing.

Confirm QL time units (per day/28/365) when prescribing

Quantity limits are routinely specified per day, per 28 days, or per 365 days alongside PA; confirm the exact QL unit (per day/28/365) on the formulary and request exception if clinically indicated.

Verify age‑based PA and QL for quetiapine formulations

Quetiapine formulations require PA for members age 17 and younger and have formulation‑specific QLs; verify age‑based PA and the applicable QL for the chosen quetiapine formulation.

Check formulation‑specific PA and QL for risperidone

Risperidone formulations require PA for members age 17 and younger and list QLs by formulation (e.g., microspheres QL 2 per 28 days, oral solution QL 8 per day); check the exact formulation line for the correct QL before prescribing.

Ensure PA and specialty routing for MS agents and observe QLs

Multiple sclerosis agents frequently require PA, SP, and sometimes Step Therapy (ST) with QLs (examples include COPAXONE, GILENYA, MAVENCLAD); ensure PA and SP routing and that QL limits are observed.

Obtain PA and route to specialty pharmacy for specialty agents

Specialty nasal or other high‑cost specialty agents (e.g., SPRAVATO) require PA and are designated SP with specific per‑28‑day QLs; obtain PA and coordinate specialty pharmacy fulfillment per the formulary.

KESIMPTA: PA, SP designation, and QL 0.4 per 28 days

KESIMPTA PEN requires Prior Authorization, is designated Specialty (SP), and has a QL of 0.4 per 28 days; include these exact requirements in the authorization submission and arrange SP fulfillment.

Follow product‑specific combos of ST/PA/SP/QL (e.g., PLEGRIDY, PONVORY)

Formulary examples show combined requirements such as ST; SP; QL (1 per 28 days) for PLEGRIDY and PA; SP; QL for PONVORY — confirm and follow the exact combination of ST/PA/SP/QL when prescribing these products.

Cite exact PA/SP/QL values (e.g., VUMERITY, TASCENSO) in requests

Examples across the formulary list PA and QL details for products (e.g., VUMERITY: PA; SP; QL 4 per 1 day; TASCENSO ODT: PA; SP; QL 1 per 1 day); ensure authorization requests cite the precise PA/SP/QL values shown.

Verify PA/ST/QL for antihypertensive products

Many antihypertensives show utilization controls including PA, ST, and QLs (for example, ENBUMYST listed with PA; LA; QL 120 per 30 days); verify antihypertensive product requirements before prescribing.

Review formulary line for utilization controls before prescribing

Most listed drugs are subject to utilization controls such as PA, QL, ST, and SP; review the formulary line to determine required prescriber actions and documentation prior to dispensing.

Check utilization flags to avoid denials

The formulary uses flags (PA, QL, SP, LA, ST) extensively; check these flags per product to avoid coverage denials or claim rejections.

Obtain PA and SP for dermatology biologics and follow QLs

Dermatology biologics commonly require Prior Authorization and many also require Specialty (SP) and specific Quantity Limits (per 28/42/63 days); obtain PA and arrange SP fulfillment as required for biologics.

Confirm authorization pathway (PA/SP/ST/QL) for each agent

Many agents require prior authorization; some require site‑of‑care prior authorization or specialty pharmacy routing, step therapy, and quantity limits — confirm the exact authorization pathway for each agent before prescribing.

Follow product‑level controls (e.g., DUPIXENT, EUCRISA, OPZELURA)

Product‑level examples: DUPIXENT requires PA, SP, and QL; EUCRISA requires ST; OPZELURA requires PA, SP, and QL — follow these specified controls when submitting authorization requests.