CurrentAvMedPolicy N/A

Prior authorization and step-edit request for insomnia medications

Form and criteria governing prior authorization and step-therapy requirements for selected prescription insomnia drugs for AvMed members; applies to prescribers requesting coverage for listed medications.

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit request for insomnia medications

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must submit a signed prior authorization form with supporting documentation and fax to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5drugs listed on form

2required failed therapies

30dmin trial duration

Fax: 1-305-671-0200submission fax

Coverage Criteria for Insomnia Medications

Approval criteria

Covered when ALL of the following are met

Primary conditions: Prescriber submits a signed request with required member and prescriber information and provides supporting documentation (labs, diagnostics, chart notes).

Signature must be handwritten; preprinted stamps not valid. Authorization may be delayed or denied if documentation is incomplete or missing.

Step therapy for quazepam and ramelteon: Member has tried and failed at least 30 days of therapy with two (2) of the following medications: eszopiclone; temazepam; zaleplon; zolpidem or zolpidem CR.2 agents, >=30 days each

All criteria must be met for approval. Previous therapies may be verified through pharmacy paid claims or submitted chart notes.

Step therapy for Belsomra, Dayvigo, Quviviq:

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit request for insomnia medications

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must submit a signed prior authorization form with supporting documentation and fax to 1-305-671-0200.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the insomnia agents listed on the request form. The prescribing provider must submit the completed and signed prior authorization form along with all required supporting documentation (lab results, diagnostics, and chart notes). Fax the completed form to 1-305-671-0200. If the information provided is incomplete, incorrect, or illegible, the authorization process can be delayed or denied.

Fax number: 1-305-671-0200
Authorization may be delayed or denied if form is incomplete, incorrect, or illegible

Documentation Required

Form Completion and Signature

The prescriber must sign and clearly print their name on the request (preprinted stamps are not valid). Include member and prescriber details: member name, AvMed ID number, date of birth, prescriber name, prescriber signature and date, office contact name, phone number, fax number, and NPI. Office staff may complete other fields, but the prescriber signature is required for the request to be processed.

Required fields: Member name, Member AvMed #, DOB, Prescriber name, Prescriber signature & date, Office contact, Phone, Fax, NPI
Preprinted signature stamps are not valid

Step Therapy

Step-Edit / Failure Trials

Step-therapy (failure trials) requirements apply. Approval requires documentation that the member has tried and failed at least 30 days of therapy with two (2) of the specified alternative medications. For Belsomra®, Dayvigo®, and Quviviq™ requests, the member must also have tried and failed at least 30 days of ramelteon (Rozerem®) 8 mg tablets (ramelteon requires prior authorization). 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.

Required failures: at least 30 days each of two of: eszopiclone; temazepam; zaleplon; zolpidem or zolpidem CR
Additional requirement for Belsomra®, Dayvigo®, Quviviq™: 30-day trial and failure of ramelteon (Rozerem®) 8 mg
Use of samples does NOT meet step-edit criteria
Previous therapies may be verified via pharmacy claims or chart notes

Documentation Required

Required Supporting Documentation

Provide documentation to support each clinical criterion checked on the form. Supporting documentation may include lab results, diagnostic testing, and chart notes. Missing or insufficient supporting documentation may result in denial or delay of the authorization.

All criteria checked must be supported with documentation
Examples: lab results, diagnostics, chart notes

Denial Risk

Incomplete or Insufficient Documentation

Incomplete, incorrect, or illegible requests — or requests missing required documentation — can be delayed or denied. Ensure all required fields are completed, the prescriber signature is present, and all supporting documentation is attached to avoid processing delays.

Incomplete/insufficient documentation may delay or deny authorization
Verify completeness before faxing to 1-305-671-0200

Required trial	Agents (examples)	Minimum duration	Verification / documentation
Step therapy for Belsomra, Dayvigo, Quviviq	Eszopiclone; Temazepam; Zaleplon; Zolpidem or Zolpidem CR	>= 30 days per agent	Trials must be documented; prior therapies may be verified through pharmacy paid claims or submitted chart notes.
Additional ramelteon requirement (Belsomra, Dayvigo, Quviviq)	Ramelteon (Rozerem) 8 mg tablets	>= 30 days	Ramelteon requires prior authorization; documentation of 30‑day trial failure required (can be verified via claims or chart notes).

OpenPayer

Prior authorization and step-edit request for insomnia medications

Coverage Criteria for Insomnia Medications

Coding and Claim Information

Provider Submission and Documentation Requirements

Background

Key Definitions

Initial Therapy Requirements

Step Therapy Documentation