CurrentAvMedPolicy N/A

Pharmacy prior authorization and step-edit for saliva substitutes

Form and criteria governing prior authorization and step-edit requirements for selected saliva substitute products (Aquoral, Caphosol, NeutraSal, SalivaMax, Salivate Rx) for AvMed members; applies to prescribers and pharmacy staff submitting PA requests.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and step-edit for saliva substitutes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and hand-sign the PA/step-edit request form and fax it to 1-305-671-0200 with required supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120max authorized for supersaturated calcium phosphate rinses

1max authorized for Aquoral

30 daysrequired trial duration (step therapy)

Coverage Criteria

Initial authorization criteria

Covered when ALL of the following are met

Form completion and signature: Prescriber has signed and completed the PA form with all required member and prescriber information

Prescriber signature must be handwritten (preprinted stamps not valid); incomplete forms may delay or result in denial

Documentation: Supporting documentation (lab results, diagnostics, and/or chart notes) is provided for each checked clinical criterion

Missing documentation may result in denial; previous therapies may be verified through pharmacy paid claims or submitted chart notes

Product-specific step therapy for mucositis: For mucositis indication, two boxes must be checked: trial and failure of Magic Mouthwash for 30 days (must be verified by pharmacy paid claims) AND either trial/failure of lidocaine 2% viscous solution for 30 days (must be verified by pharmacy paid claims) OR trial/failure of Biotene dry mouth products for 30 days

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and step-edit for saliva substitutes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and hand-sign the PA/step-edit request form and fax it to 1-305-671-0200 with required supporting documentation.

SourceLink

On This Page

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Initial Therapy / Step Requirements

Initial therapy/step requirements

Initial approvals require documented prior trials and failures as specified below.

Mucositis initial therapy: Must document trial and failure of Magic Mouthwash for 30 days AND trial/failure of lidocaine 2% viscous for 30 days OR trial/failure of Biotene products for 30 days; two boxes must be checked on form30 days

Trials must be verified by pharmacy paid claims or chart notes

Xerostomia initial therapy: Must document trial and failure of Mouth Kote solution for 30 days OR trial/failure of Biotene products for 30 days; one box must be checked on form30 days

Trials must be verified by pharmacy paid claims or chart notes; use of samples to initiate therapy does not meet criteria

Indication	Required prior therapies (trial & failure)	Required trial duration / verification
Oral mucositis	Trial and failure of Magic Mouthwash AND (trial and failure of lidocaine 2% viscous solution OR trial and failure of Biotene dry mouth products)	30 days each; trials must be verified by pharmacy paid claims or chart notes
Xerostomia / Hyposalivation	Trial and failure of Mouth Kote solution OR trial and failure of Biotene dry mouth products	30 days; trial must be verified by pharmacy paid claims or chart notes

Quantity Limits by Product

Supersaturated calcium phosphate rinses (Caphosol, NeutraSal, SalivaMax, Salivate Rx) — 120

ProductsCaphosol; NeutraSal; SalivaMax; Salivate Rx

Drug class / descriptionSupersaturated calcium phosphate rinse

Quantity limitMaximum of 120 unit doses per 30 days

Indications referencedOral mucositis and xerostomia/hyposalivation as documented on the PA form

Aquoral — 1

ProductAquoral

Drug descriptionOxidized glycerol triesters (saliva substitute)

Quantity limitMaximum of 1 unit (40 mL) per 30 days

Indications referencedOral mucositis and xerostomia/hyposalivation as documented on the PA form

Maximum units for supersaturated calcium phosphate rinses

Threshold120 unit doses per 30 days

Applies toCaphosol; NeutraSal; SalivaMax; Salivate Rx (supersaturated calcium phosphate rinses)

NotesIf approved, authorizations will not exceed this quantity per 30 days

Maximum units for Aquoral

Threshold1 unit (40 mL) per 30 days

Applies toAquoral (oxidized glycerol triesters)

NotesIf approved, authorizations will not exceed this quantity per 30 days

Provider Submission & Documentation Requirements

Prior Authorization

Submission and signature requirement

The prescribing provider must complete, sign (handwritten; preprinted stamps not valid), and print their name on the PA/step-edit request form and fax the completed form to 1-305-671-0200. Include a provider contact phone and fax number; if any required information is incomplete, incorrect, or illegible the authorization process may be delayed or denied.

Fax: 1-305-671-0200
Prescriber signature and printed name required (stamps not valid)
Include office contact name, phone number, fax number, DEA or NPI

Step Therapy

Step-edit (trial & failure) requirements

Approvals require documented trials and failures of the specified prior therapies for the durations listed (typically 30 days). Trials will be verified by pharmacy paid claims when available; if claims are not available, submit chart notes or other supporting documentation. Use of samples does NOT meet step-edit/preauthorization requirements.

Step-edit trials: typically 30 days per listed agent
Trials verified via pharmacy paid claims or chart notes
Samples cannot be used to satisfy step therapy

Documentation Required

Required form fields and supporting documentation

The form must include all required member and prescriber fields. Missing member or drug information may delay processing. Provide: member name, AvMed member number, date of birth; prescriber name, handwritten signature, date; office contact name, phone and fax; DEA or NPI. For the drug request include drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, and date. If approved, authorization limits: supersaturated calcium phosphate rinses — maximum 120 unit doses per 30 days; Aquoral — maximum 1 unit (40 mL) per 30 days.

Member name, AvMed #, DOB
Prescriber name, handwritten signature, date
Office contact name, phone, fax, DEA or NPI
Drug form/strength, dosing schedule, length of therapy, diagnosis, ICD code, weight, date
Authorization maximums: 120 unit doses/30 days for supersaturated calcium phosphate rinses; 1 unit (40 mL)/30 days for Aquoral

Denial Risk

Incomplete information or missing documentation

If the form information or supporting documentation (including verification of prior therapies via pharmacy paid claims or chart notes) is incomplete, incorrect, or illegible, the authorization may be delayed or denied. To support each checked clinical criterion, include all relevant documentation (lab results, diagnostics, chart notes).

Incomplete/illegible forms may delay or result in denial of authorization
Provide lab results, diagnostics, or chart notes to support clinical criteria
Ensure trials/failures are documented or verifiable

Background

Supersaturated calcium phosphate rinses and saliva substitutes are used to manage symptoms of oral mucositis and xerostomia/hyposalivation. For mucositis, the form requires documentation of trials and failures of specified prior therapies — for example, a 30-day trial and failure of Magic Mouthwash plus either a 30-day trial and failure of lidocaine 2% viscous solution or a 30-day trial and failure of Biotene dry mouth products. For xerostomia/hyposalivation, the form requires a 30-day trial and failure of Mouth Kote solution or a 30-day trial and failure of Biotene dry mouth products.

All prior therapy trials must be verified by pharmacy paid claims or submitted chart notes. The form explicitly states that use of samples to initiate therapy does not meet step edit/preauthorization criteria, so documented paid-claim evidence or clinical chart documentation is required to demonstrate medical necessity.

OpenPayer

Pharmacy prior authorization and step-edit for saliva substitutes

Coverage Criteria

Initial Therapy / Step Requirements

Continuation / Quantity Limits

Quantity Limits by Product

Diagnosis and Coding

Provider Submission & Documentation Requirements

Definitions

Background