CurrentAvMedPolicy N/A

Arformoterol Nebulizer Solution

Pharmacy prior authorization / step-edit request form and clinical criteria for coverage of arformoterol nebulizer solution (Brovana) including required prescriber/member information, dosing recommendation, and step therapy failure requirement.

Policy Summary

PayerAvMed

PolicyArformoterol Nebulizer Solution

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and print name on the request form and submit all required member, prescriber, and drug information via fax to 1-305-671-0200; incomplete, incorrect, or illegible information may delay authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Required prior therapy

15 mcg twice dailyTypical dose

Coverage Summary

This document is a pharmacy prior authorization / step-edit request form and the clinical criteria for coverage of arformoterol nebulizer solution (Brovana). It requires completed member and prescriber information (including prescriber signature and contact details), drug information (form/strength, dosing schedule, length of therapy, diagnosis, ICD code if applicable, weight, date), and documentation supporting the clinical criteria for approval.

The dosing recommendation specified is 15 mcg twice daily; maximum: 30 mcg/day. Approval requires meeting all listed clinical criteria and submission of supporting documentation (e.g., pharmacy paid claims or chart notes).

Initial Therapy Criteria

Clinical Criteria for Approval

All criteria must be met for approval. To support each line checked, documentation must be provided.

Member has had an unsuccessful 30-day trial of Serevent Diskus 50 mcg/dose inhaler (verified by pharmacy paid claims)30-day trial

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

Provider Actions

Prior Authorization

Submit prior authorization / step-edit request

Prescribing physician must sign and clearly print name (preprinted stamps not valid) on the request form and submit all required member, prescriber, and drug information via fax to 1-305-671-0200. No additional phone calls will be necessary if all information (including phone and fax numbers) on this form is correct. If the information provided is not complete, correct, or legible, the authorization process can be delayed.

Documentation Required

Provide evidence of prior therapy failure

Provide documentation (pharmacy paid claims or chart notes) verifying an unsuccessful 30-day trial of Serevent Diskus 50 mcg/dose inhaler. Use of samples to initiate therapy does not meet step edit/preauthorization criteria and cannot be used to satisfy the prior therapy requirement. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Background

Background: This is a pharmacy prior authorization/step-edit form for arformoterol nebulizer solution (generic Brovana & ABA). The form collects member and prescriber details (including prescriber signature and contact information), drug information (dosing schedule, recommended dosage, length of therapy), diagnosis and ICD code if applicable, and requires documentation supporting the clinical criteria for approval.

Definitions: "Samples" — Drug samples used to initiate therapy do not meet step edit/preauthorization criteria and cannot be used to satisfy prior therapy requirements.

Revision History

CURRENT_STATUSLatest

Policy status: CURRENT. This is a pharmacy prior authorization/step-edit request form for arformoterol nebulizer solution (Brovana). The form requires prescriber signature and complete member/prescriber/drug information to be faxed to 1-305-671-0200; incomplete, incorrect, or illegible information may delay authorization. Clinical criteria require all listed criteria be met for approval and documentation (pharmacy paid claims or chart notes) must be provided. Use of samples does not meet step edit/preauthorization criteria. Recommended dosage: 15 mcg twice daily; maximum 30 mcg/day. A 30-day trial of Serevent Diskus 50 mcg/dose inhaler must be documented as unsuccessful to meet step therapy requirement.