CurrentAvMedPolicy N/A

Penciclovir (Denavir) pharmacy prior authorization

Prior authorization and step-edit requirements for penciclovir (Denavir) topical therapy for AvMed members; governs prescribers and pharmacy processing for covered plans.

Policy Summary

PayerAvMed

PolicyPenciclovir (Denavir) pharmacy prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the PA/step-edit request form and supply documentation that all listed clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 gquantity limit per prescription

>=30 drequired oral trial

3oral options

Coverage Criteria

Initial therapy

Covered when ALL of the following are met

Penciclovir approval criteria: Member is immunocompetent

checkbox on form

Diagnosis: Member has been diagnosed with recurrent herpes labialis (cold sores)

checkbox on form

Topical therapy failure: Member has tried and failed topical acyclovir 5% ointment (verified by chart notes or pharmacy paid claims)

checkbox on form

Oral antiviral failure:

Policy Summary

PayerAvMed

PolicyPenciclovir (Denavir) pharmacy prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the PA/step-edit request form and supply documentation that all listed clinical criteria are met.

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 Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Penciclovir (Denavir) requires prior authorization. The prescriber must complete the PA/step-edit request form and supply all required documentation (including phone and fax numbers). If the information provided is not complete, correct, or legible, the authorization process can be delayed.

Fax completed form to 1-305-671-0200
Include phone and fax numbers on the form to avoid delays

Step Therapy

Step Therapy and Failure Requirements

Step therapy and failure requirements — All criteria must be met for approval. Member must be immunocompetent, diagnosed with recurrent herpes labialis, have tried and failed topical acyclovir 5% ointment, and have tried and failed at least 30 days of therapy with one of the following oral agents: acyclovir, famciclovir, or valacyclovir (verified by chart notes or pharmacy paid claims). Use of samples to initiate therapy does not satisfy step-edit requirements.

Documentation of prior therapy must be provided (chart notes or pharmacy paid claims)
Previous therapies will be verified through pharmacy paid claims or submitted chart notes

Documentation Required

Provider Form Signature and Required Fields

Provider form signature and required fields — The prescribing physician must hand-sign and clearly print their name on the request (preprinted stamps are not valid). Include member and prescriber details, diagnosis and ICD code if applicable, dosing schedule, length of therapy, weight, date, DEA or NPI number, office contact, phone and fax numbers.

Prescriber signature must be hand-signed (no preprinted stamps)
Include Member AvMed #, DOB, prescriber name, date, office contact, phone and fax numbers, and DEA or NPI #
Provide drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight, and date

Denial Risk

Authorization Risk and Missing Documentation

Authorization risk and missing documentation — Authorization can be delayed or the request may be denied if the request form or required documentation (including phone/fax numbers, clinical documentation, lab results, diagnostics, and chart notes verifying prior therapies) is missing, incomplete, incorrect, or illegible.

All documentation supporting each checked clinical criterion must be provided or the request may be denied
Samples used to initiate therapy do not meet step-edit/preauthorization criteria

Initial Therapy Requirements

Initial therapy requirements

Approval requires documented trials and failures of listed therapies.

Initial penciclovir criteria: Member is immunocompetent; diagnosed with recurrent herpes labialis; failed topical acyclovir 5% ointment; failed >=30 days of one oral antiviral (acyclovir, famciclovir, or valacyclovir)

All items must be documented; verification via chart notes or pharmacy paid claims

OpenPayer

Penciclovir (Denavir) pharmacy prior authorization

Coverage Criteria

Coding and Clinical Parameters

Provider Actions and Documentation Requirements

Background

Definitions

Initial Therapy Requirements

Step Therapy Requirements

Quantity Limits