CurrentAvMedPolicy N/A

Pharmacy prior authorization and step-edit for Savella (milnacipran HCL)

Form and clinical criteria governing prior authorization/step-edit requests for Savella (milnacipran HCL) for AvMed members; applies to prescribers requesting coverage via the pharmacy prior authorization process.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and step-edit for Savella (milnacipran HCL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization form with prescriber handwritten signature and required clinical documentation; fax to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1drug covered by this form (Savella)

4alternative generics listed

1handwritten prescriber signature required

multiplerevision dates in footer

Coverage & Step-Edit Requirements

Step-edit approval criteria

Covered when ALL of the following are met:

Primary criteria: Member has tried and failed 30 days of therapy with TWO of the following generic medications: duloxetine, gabapentin, lidocaine 5% topical patches, pregabalin.2 agents each for 30 days

Use of samples to initiate therapy does not meet criteria; previous therapies will be verified through pharmacy paid claims or chart notes

Use of medication samples to initiate therapy does not meet the step edit / preauthorization criteria. Requests must document completed trials of the required alternatives; samples alone will not satisfy the step-therapy requirement and prior therapies will be verified through pharmacy paid claims or submitted chart notes.

Diagnosis, Codes, and Step Length

Diagnosis fieldICD-10

ICD code (field)

ICD Code, if applicable (to be provided on form)

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and step-edit for Savella (milnacipran HCL)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization form with prescriber handwritten signature and required clinical documentation; fax 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.

Step therapy trial length

Step therapy trial length30 days

Step therapy duration applies to each alternative agentEach required trial = 30 days

Documented verification of prior therapyPrevious therapies will be verified through pharmacy paid claims or submitted chart notes

Submission, Documentation, and Signature Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for this drug. Submit the completed Prior Authorization/Step-Edit Request form with the prescriber's original signature and all required clinical documentation. Fax the form and supporting records to 1-305-671-0200. Incomplete, incorrect, or illegible information may delay processing or result in denial.

Fax: 1-305-671-0200
Use the official Prior Authorization/Step-Edit Request form

Step Therapy

Step Therapy Requirement

Member must have tried and failed 30 days of therapy with TWO of the listed generic medications prior to approval. Use of samples to initiate therapy does not meet the step-edit/preauthorization requirement. Document previous therapies; pharmacy paid claims may be used to verify prior use.

Required trial medications (examples): duloxetine, gabapentin, lidocaine 5% patch, pregabalin
Trials must be 30 days each; two different agents required

Documentation Required

Supporting Documentation Required

Provide documentation to support each checked clinical criterion. Required supporting documentation includes relevant lab results, diagnostic testing, and chart notes that document prior therapies and treatment response. Failure to provide adequate supporting documentation may result in delay or denial of the request.

Attach chart notes and lab/diagnostic reports
Include pharmacy claims or documentation of prior medication trials

Documentation Required

Prescriber Signature and Contact Information

The prescriber must sign and clearly print their name on the request (preprinted stamps are not valid). Include prescriber contact information, office contact name, phone and fax numbers, and DEA or NPI number. Dates must be provided where indicated. Omitting the prescriber signature or contact information may delay authorization.

Prescriber signature (original) — preprinted stamps not acceptable
Prescriber printed name, phone, fax, office contact, DEA or NPI number
Date of signature

Denial Risk

Incomplete or Insufficient Documentation

If the form is incomplete, incorrect, or illegible, the authorization process can be delayed or the request may be denied. Ensure all sections of the form are completed and that supporting documentation is included to avoid denials or processing delays.

Incomplete forms may result in delays or denials
Ensure legible entries and all required attachments are included

Drug Background

Savella (milnacipran HCL) is managed under a step-edit prior authorization process that requires documented failure of specified alternatives before approval. Specifically, the member must have tried and failed 30 days of therapy with two of the listed generic medications (duloxetine, gabapentin immediate release, lidocaine 5% topical patches, pregabalin immediate release); all supporting documentation (labs, diagnostics, chart notes) must be provided or the request may be denied.

Definitions & Requirements

Step-edit / Preauthorization requirements

Step-edit requirementMember must have tried and failed 30 days of therapy with TWO of the following generic medications: duloxetine; gabapentin; lidocaine 5% topical patches; pregabalin.

Agents listedduloxetine (20, 30, or 60 mg), gabapentin immediate release, lidocaine 5% patches, pregabalin immediate release

Samples do not countUse of medication samples to initiate therapy does not meet step edit/preauthorization criteria.

Supporting documentation requiredTo support each line checked, provide documentation including lab results, diagnostics, and/or chart notes; requests may be denied without it.

Initial Approval Requirements

Initial therapy requirements

Initial approval requires documented failures of alternatives

Initial therapy step-edit: Failure of TWO of: duloxetine (20, 30, or 60 mg), gabapentin immediate release, lidocaine 5% topical patches, pregabalin immediate release — each for 30 days.2 agents, 30 days each

Samples do not count; documentation required

Required Prior Therapies

Requirement	Alternatives (must fail TWO, 30 days each)
Member must have tried and failed the following prior therapies before Savella (milnacipran HCL) will be approved
duloxetine (Cymbalta) 20, 30, or 60 mg capsules; gabapentin (Neurontin) immediate release capsules; lidocaine (Lidoderm) 5% topical patches; pregabalin (Lyrica) immediate release capsules