CurrentAvMedPolicy N/A

Pharmacy prior authorization form for ethacrynic acid (Edecrin)

This document is a prior authorization/step-edit request form that governs authorization for ethacrynic acid (Edecrin) prescriptions for AvMed members; it specifies required prescriber and clinical documentation and step therapy requirements for approval.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization form for ethacrynic acid (Edecrin)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization on this form with prescriber signature and fax to 1-305-671-0200 including all required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2explicit clinical criteria that must be met

1drug named on form

1fax number for submission

samples not acceptablepolicy note

Coverage and Authorization Criteria

Authorization criteria

Approval requires ALL of the following:

Main criteria: Provider must submit the required prior authorization/step-edit request form with a handwritten prescriber signature (preprinted stamps not valid) and complete member and prescriber information, including drug requested; all documentation, including labs or chart notes when required, must be provided

Form must be faxed to 1-305-671-0200

Clinical conditions: Documentation of a sulfa allergy (medical notes must be submitted for verification) OR documentation of trial and failure of a loop or thiazide diuretic

Use of samples to initiate therapy does not meet step edit/preauthorization criteria

Use of drug samples to initiate therapy does not satisfy the step-edit / prior authorization requirement. Documentation of a completed trial and failure of other loop or thiazide diuretics, or documentation of a sulfa allergy, must be submitted as specified on the form for approval; samples alone will not meet these criteria.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization form for ethacrynic acid (Edecrin)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization on this form with prescriber signature and fax to 1-305-671-0200 including all required clinical documentation.

SourceLink

On This Page

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Submission, Documentation, and Provider Requirements

Prior Authorization

Submission requirement — Prior Authorization

Prior Authorization Required: A completed prior authorization request must be submitted using the pharmacy prior authorization/step-edit request form and faxed to 1-305-671-0200 with the prescriber's handwritten signature. Preprinted signature stamps are not valid. Include complete office contact phone and fax numbers to avoid processing delays.

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

Step Therapy

Step-edit overview

All clinical criteria listed on the form must be met for approval. The form requires that providers check every applicable clinical box; previous therapies will be verified via pharmacy paid claims or submitted chart notes. Use of samples to initiate therapy does not satisfy step-edit or prior authorization requirements.

ALL criteria on the form must be met for approval
Previous therapies verified via pharmacy claims or chart notes
Samples do not meet step-edit requirements

Documentation Required

Required submission information

Required submission information: Prescriber must sign and clearly print name (handwritten signature; stamps not valid). Complete member and prescriber details must be provided to avoid delays. Include: member name, AvMed ID number, date of birth; prescriber name, prescriber signature and date, office contact name, phone and fax numbers, DEA or NPI number. Drug-specific details required: drug name, form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), patient weight, and date. If documentation (labs or chart notes) is required by the criteria, attach them with the request.

Member name, AvMed ID, DOB
Prescriber name, handwritten signature, date
Office contact name, phone, fax
DEA or NPI number
Drug form/strength, dosing schedule, length of therapy
Diagnosis and ICD code (if applicable), weight, date
Attach required labs or chart notes

Denial Risk

Denial triggers

Denial triggers: Requests will be denied if required documentation (including labs or chart notes) is not submitted, or if information on the form is incomplete, incorrect, illegible, or missing. Documentation of sulfa allergy must include medical notes for verification. Initiation with sample medication does not satisfy criteria and may result in denial.

Missing or incomplete documentation
Illegible or incorrect information on form
No medical notes verifying sulfa allergy when claimed
Use of samples to initiate therapy

Key Definitions

inv-09: Trial and failure of a loop or thiazide diuretic — definition / required evidence

DefinitionTrial and failure of a loop or thiazide diuretic means the member has previously used one or more loop or thiazide diuretics and those therapies were ineffective or not tolerated as documented in the medical record.

Required evidenceMedical chart notes or pharmacy claim history documenting prior use of other loop or thiazide diuretics and reason for discontinuation (lack of efficacy or intolerance).

Verification methodPrevious therapies will be verified via pharmacy claims or chart notes as part of the step-edit review.

SamplesUse of medication samples to initiate therapy does not satisfy the requirement for trial and failure of other diuretics.

Related actionInclude specific drug name(s), treatment dates, and clinical rationale in submitted documentation to support the trial/failure claim.

inv-10: Documentation of a sulfa allergy (medical notes must be submitted for verification)

RequirementDocumentation of a sulfa allergy must be submitted in the member’s medical notes for verification.

Acceptable evidenceMedical chart notes or other clinical documentation that clearly state the sulfa allergy and clinical consequences or testing results.

Submission instructionAttach the relevant medical notes to the prior authorization request form when faxing to 1-305-671-0200.

VerifierClinical reviewer will confirm allergy documentation as part of the authorization review; incomplete or missing notes may delay or result in denial.

Prescriber signaturePrescribing physician must sign and clearly print name on the request; preprinted stamps are not valid.

OpenPayer

Pharmacy prior authorization form for ethacrynic acid (Edecrin)

Coverage and Authorization Criteria

Diagnosis and Billing Codes

Submission, Documentation, and Provider Requirements

Clinical Background

Key Definitions

Initial Therapy Requirements

Step Therapy and Prior Trial Requirements