CurrentAvMedPolicy N/A

Pharmacy prior authorization / step-edit for oral erectile dysfunction agents

Form and criteria that govern prior authorization requests for vardenafil (Levitra) and avanafil (Stendra) for AvMed members; applies to prescribers seeking coverage for these oral erectile dysfunction drugs.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization / step-edit for oral erectile dysfunction agents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed prior authorization form with required documentation to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2drugs listed on form

2required prior failures for approval

1fax number for submission

1clinical checklist requiring documentation

Coverage Criteria

Initial authorization criteria

Covered when ALL of the following are met

Step therapy and documentation: Member has documented history of failure, contraindication, or intolerance to tadalafil AND sildenafil (must submit chart notes documenting date tried and reason for failure).both agents failed/contraindicated/intolerant

Concomitant use of oral medications for erectile dysfunction is NOT a covered benefit; previous therapies may be verified through pharmacy paid claims or submitted chart notes. Use of drug samples to initiate therapy does not meet step edit/preauthorization criteria.

Concomitant use of oral medications for erectile dysfunction is NOT a covered benefit. Requests that indicate concurrent use of more than one oral PDE5 inhibitor will not meet coverage criteria and should not be submitted for authorization.

Use of drug samples to initiate therapy does not meet step edit/preauthorization criteria. Coverage decisions require documentation of formal trials (or verified pharmacy claims) of prior agents; sample use alone is not acceptable evidence of a required prior trial.

Coding

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization / step-edit for oral erectile dysfunction agents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax completed prior authorization form with required documentation 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.

ICD-10 diagnosis code (form field)ICD-10

ICD code, if applicable (field provided on form)

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Fax completed form to 1-305-671-0200 with required information. The prescribing physician must sign and clearly print name (preprinted stamps not valid) on this request. All other information may be filled in by office staff. If the information provided is not complete, correct, or legible, the authorization process can be delayed.

Fax number: 1-305-671-0200
Prescriber signature and printed name required (stamps not valid)

Step Therapy

Step-Edit Requirement

Step-edit requirement — All criteria must be met for approval, including documented failure, contraindication, or intolerance to both tadalafil and sildenafil prior to approval of vardenafil (Levitra) or avanafil (Stendra). Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Step therapy requires documented trial (date tried) and reason for failure for both tadalafil and sildenafil
Concomitant use of oral ED medications is not a covered benefit

Documentation Required

Required Supporting Documentation

Required supporting documentation — The prescriber must provide documentation (lab results, diagnostics, and chart notes) supporting each checked clinical criterion, including dates tried and reasons for failure; previous therapies will be verified through pharmacy paid claims or submitted chart notes. Failure to provide adequate documentation can lead to denial.

Provide chart notes documenting dates of trials and reasons for failure for tadalafil and sildenafil
Include relevant lab results or diagnostic reports as applicable

Note

Administrative Information Required

Administrative information required — Include member name, AvMed member ID, date of birth, prescriber name, prescriber signature, date, office contact name, phone and fax numbers, and DEA or NPI number. Incomplete, incorrect, or illegible information may delay or result in denial of authorization.

Member Name, AvMed ID, Date of Birth
Prescriber Name, Prescriber Signature, Date
Office contact name, phone number, fax number
DEA or NPI #

Denial Risk

Incomplete Request / Insufficient Documentation

Incomplete or incorrect requests — Incomplete, incorrect, or illegible information may delay processing or result in denial. Failure to provide chart notes or documentation verifying prior trials and reasons for failure can lead to denial of the authorization request.

Incomplete/illegible forms may be delayed or denied
Missing chart notes verifying prior therapy trials and reasons for failure may result in denial

Background

This form governs prior authorization for oral therapies used to treat erectile dysfunction and enforces a step-therapy requirement. Approval is contingent on meeting all clinical criteria on the form, including documented failure, contraindication, or intolerance to both tadalafil and sildenafil with chart notes showing dates and reasons for failure. Providers must supply supporting documentation (chart notes or pharmacy paid-claim verification); incomplete documentation may delay or result in denial.

Definitions

Step-edit failure requirement

Step-edit failure requirementMember must have history of failure, contraindication, or intolerance to BOTH tadalafil (Cialis) and sildenafil (Viagra); chart notes must be submitted documenting the date tried and reason for failure.

Documentation requiredTo support each checked criterion, provide lab results, diagnostics, and/or chart notes; requests lacking these may be denied.

Agents specifiedRequired prior agents: tadalafil (generic Cialis) AND sildenafil (generic Viagra).

Concomitant use exclusionConcomitant use of oral medications for erectile dysfunction is NOT a covered benefit.

Initial Therapy Criteria

Initial therapy requirements

Initial approval requires documented prior therapy failures

Prior trials required: Documented failure, contraindication, or intolerance to tadalafil AND sildenafil with chart notes including dates tried and reason for failure.both agents

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

Step Therapy Requirements

Step	Required prior therapies	Notes
1	Tadalafil (generic Cialis) — history of failure, contraindication, or intolerance	Must submit chart notes documenting date tried and reason for failure; previous therapies may be verified through pharmacy paid claims or submitted chart notes.
2	Sildenafil (generic Viagra) — history of failure, contraindication, or intolerance	All criteria must be met for approval; concomitant use of oral ED medications is not a covered benefit; use of samples to initiate therapy does not meet step edit/preauthorization criteria.