CurrentAvMedPolicy N/A

Prior Authorization and Step-Edit Criteria for Non‑Preferred Albuterol/Levalbuterol Inhalers

This form governs prior authorization and step-edit requests for non-preferred albuterol and levalbuterol inhalers for AvMed members; it affects prescribers requesting coverage for listed non-preferred inhalers.

Policy Summary

PayerAvMed

PolicyPrior Authorization and Step-Edit Criteria for Non‑Preferred Albuterol/Levalbuterol Inhalers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit clinical chart notes or a completed MedWatch form documenting intolerance or treatment failure with Ventolin® HFA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5listed non-preferred inhaler options on form

1preferred albuterol inhaler called out

2required supporting documents

1fax number for submission

Coverage Criteria

Initial Approval Criteria

Covered when ALL of the following are met

Primary requirements: For approval of any non-preferred albuterol/levalbuterol inhaler: Member must have an intolerance or contraindication to Ventolin® HFA (albuterol sulfate).

All documentation including lab results, diagnostics, and/or chart notes must be provided or request may be denied.

Supporting documentation: Provider must submit clinical chart notes or a completed MedWatch form documenting the experienced treatment failure with brand Ventolin® HFA (albuterol sulfate).

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

Use of samples to initiate therapy does not meet step edit or preauthorization criteria. Requests for non-preferred albuterol or levalbuterol inhalers will not be approved based solely on a trial with samples; supporting documentation must show intolerance/contraindication to the preferred product and documented treatment failure with Ventolin® HFA.

Policy Summary

PayerAvMed

PolicyPrior Authorization and Step-Edit Criteria for Non‑Preferred Albuterol/Levalbuterol Inhalers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit clinical chart notes or a completed MedWatch form documenting intolerance or treatment failure with Ventolin® HFA.

SourceLink

On This Page

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Step	Requirement	Supporting documentation	Coverage status
1
Member must have an intolerance or contraindication to Ventolin® HFA (albuterol sulfate).
Provider must submit clinical chart notes or a completed MedWatch form documenting treatment failure with brand Ventolin® HFA; all documentation (lab results, diagnostics, chart notes) must be provided or request may be denied.
Coverage of non-preferred albuterol/levalbuterol inhalers only permitted after step requirements are met.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for listed non-preferred albuterol and levalbuterol inhalers. Approval requires documentation of intolerance or contraindication to Ventolin® HFA and submission of supporting clinical documentation showing treatment failure with brand Ventolin® HFA.

Applies to non-preferred albuterol/levalbuterol inhalers (see request form list).
Fax completed form to 1-305-671-0200.

Step Therapy

Step-edit Requirement

Member must have an intolerance or contraindication to the preferred product (Ventolin® HFA) and documented treatment failure with Ventolin® HFA before a non-preferred albuterol or levalbuterol inhaler will be approved.

Step-therapy requirement: intolerance/contraindication AND documented treatment failure with Ventolin® HFA are both required.

Documentation Required

Required Supporting Documentation

Provider must submit supporting clinical documentation to verify intolerance/contraindication and treatment failure. Acceptable documentation includes clinical chart notes or a completed FDA MedWatch form describing the adverse reaction or lack of efficacy with Ventolin® HFA.

Include relevant chart notes, lab results, diagnostics, and dates of events.
Use of samples to initiate therapy does not meet step-edit/preauthorization criteria.

Documentation Required

Form Completion, Signature, and Contact Information

The prescribing physician must sign and clearly print their name on the request form (preprinted stamps are not valid). Include member and prescriber identifying information, contact phone and fax numbers, and DEA or NPI number. Incomplete, incorrect, or illegible information may delay or result in denial of the authorization.

Prescriber signature and printed name required; office staff may complete other fields.
Authorization may be delayed or denied if required information or documentation is missing.

Denial Risk

Delays or Denial for Incomplete Documentation

Incomplete, incorrect, or illegible information on the form or missing required supporting documentation can delay the authorization process or lead to denial.

Ensure all fields are complete and legible before faxing.
Missing chart notes or MedWatch form documenting Ventolin® HFA intolerance/treatment failure may result in denial.

Definitions

Non-Preferred Albuterol Inhalers

Listed non-preferred inhalersalbuterol HFA (generic ProAir® HFA); albuterol HFA (generic Proventil® HFA); albuterol HFA (generic Ventolin® HFA); levalbuterol HFA (generic Xopenex®); ProAir® Digihaler/HFA/Respiclick (albuterol sulfate); Proventil® HFA (albuterol sulfate)

Plan-preferred productVentolin® HFA is AvMed's Preferred Inhaler.

Prior authorization requirementPrior authorization is required for the listed non-preferred albuterol and levalbuterol inhalers.

Step-therapy requirementApproval requires documented intolerance/contraindication to Ventolin® HFA and documented treatment failure with Ventolin® HFA (chart notes or MedWatch form).

Submission instructionPrescribing physician must sign and clearly print name on the request; fax completed form to 1-305-671-0200.

OpenPayer

Prior Authorization and Step-Edit Criteria for Non‑Preferred Albuterol/Levalbuterol Inhalers

Coverage Criteria

Initial Therapy

Step Therapy Requirements

Provider Actions and Requirements

Definitions

Background