CurrentAvMedPolicy N/A

Prior authorization and step-edit criteria for LAMA-LABA (and LAMA-LABA-ICS) inhalers

Prior authorization form and step-edit criteria for LAMA-LABA (and LAMA-LABA-ICS) inhalers for treatment of COPD for AvMed members; governs prescribers requesting coverage for listed drugs.

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit criteria for LAMA-LABA (and LAMA-LABA-ICS) inhalers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization form with prescriber signature and required supporting documentation, faxed to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3drugs listed on form

≥18minimum patient age for approval

30d x2required trials

faxsubmission fax

COPDdiagnosis required

Coverage Criteria for LAMA-LABA Combination Inhalers

Initial approval criteria

Covered when ALL of the following are met:

Age: Patient must be > 18 years of age>18

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Diagnosis of Chronic Obstructive Pulmonary Disease (COPD)

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Prior therapy: Patient must have tried and failed at least 30 days of TWO of the following: Anoro Ellipta OR Trelegy Ellipta AND Stiolto Respimat30 days x 2 agents

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Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit criteria for LAMA-LABA (and LAMA-LABA-ICS) inhalers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization form with prescriber signature and required supporting documentation, faxed 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.

Diagnosis, Age, and Prior Therapy Coding

Diagnosis codesICD-10

ICD Code

space provided for ICD code if applicable

Minimum age requirement

Minimum agePatient must be > 18 years of age

Applies toAll requests for LAMA-LABA (and LAMA-LABA-ICS) agents on the PA form

VerificationAge must be documented on the prior authorization form or in chart notes

Prior therapy duration

Required prior therapy durationTried and failed at least 30 days of TWO listed alternatives

Specified alternativesAnoro Ellipta OR Trelegy Ellipta AND Stiolto Respimat

DocumentationPrevious therapies will be verified through pharmacy paid claims or submitted chart notes

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required. Providers must submit the completed prior authorization / step-edit request form with the prescribing physician’s original signature (preprinted stamps not valid) and ensure all required fields are complete and legible. Fax the signed form to 1-305-671-0200. Incomplete, incorrect, or illegible forms or missing documentation may delay or result in denial of the authorization.

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

Documentation Required

Form Completeness and Required Documentation

Complete all sections of the form and ensure supporting documentation is attached. Authorization may be delayed or denied if the form is incomplete, incorrect, illegible, or necessary documentation (e.g., chart notes, lab results, diagnostics) is not provided. Office staff may complete the form, but the prescribing physician must sign.

Provide drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, date
Attach chart notes, diagnostics, and/or lab results to support each checked clinical criterion

Step Therapy

Step Therapy Requirements

Step therapy requirements apply for PA LAMA-LABA (AvMed). Patient must be over 18 years of age and must have tried and failed at least 30 days of TWO of the following before approval: Anoro Ellipta OR Trelegy Ellipta AND Stiolto Respimat. Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Prior therapies will be verified via pharmacy paid claims or submitted chart notes.

Age requirement: > 18 years
Required trial/failure: 30 days of TWO agents as specified
Samples do not satisfy step therapy

Documentation Required

Required Supporting Documentation

Provide supporting documentation for each clinical criterion checked on the form. All criteria must be met for approval; to support each checked item, include relevant chart notes, diagnostics, and lab results. Failure to provide documentation for each checked criterion may result in denial.

Attach documentation for diagnosis of COPD and any relevant ICD codes
Attach evidence of prior therapy trials (pharmacy claims or chart notes)

OpenPayer

Prior authorization and step-edit criteria for LAMA-LABA (and LAMA-LABA-ICS) inhalers

Coverage Criteria for LAMA-LABA Combination Inhalers

Diagnosis, Age, and Prior Therapy Coding

What Providers Must Do

Background

Definitions

Initial Therapy Requirements

Step Therapy Requirements and Failures

Step	Requirement
1	Patient must be > 18 years of age
2	Patient must have tried and failed at least 30 days of TWO of the following: Anoro Ellipta OR Trelegy Ellipta AND Stiolto Respimat
Notes	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. Not all drugs may be covered under every plan; if non‑formulary, documentation of medical necessity required.