Prior authorization: submit completed request form and clinical documentation

The ordering prescriber must submit a completed drug authorization request form and supporting clinical documentation to AvMed by fax (1305-671-0200). Information that may be required includes lab values, prescription history, a statement of medical necessity, and any other pertinent clinical information. Urgent prior authorization decisions will be made within 24 hours; standard determinations are made within 1–3 business days.

• Submit completed drug authorization request form (available at https://www.avmed.org/prescriptions/ or https://www.avmed.org/forms/provider).
• Include supporting clinical documentation: lab values, prescription history, statement of medical necessity, and other pertinent information.
• Fax submissions to 1305-671-0200.
• Expect decisions within 24 hours for urgent requests and 1–3 business days for standard requests.

Quantity limit exceptions require prescriber medical necessity statement

If a prescription exceeds the formulary quantity limit, the prescriber must provide a statement of medical necessity and request a prior authorization for a quantity limit exception.

• Provide a statement of medical necessity documenting why the standard QL is insufficient.
• Request the QL exception via the prior authorization process described in the Prior Authorization Process section.

Step therapy: trial documentation and non‑formulary/CED prior authorization

Step therapy requires documented trials of specified first- and/or second-line medications per AvMed guidelines; non‑formulary or clinically equivalent drug requests must be supported by clinical documentation and submitted through the prior authorization process.

• Document adequate trials (and therapeutic failures or contraindications) of required step agents in the medical record.
• For non‑formulary or Clinically Equivalent Drugs (CED), submit clinical documentation establishing medical necessity; CED entries also have prior authorization requirements.
• Submit requests via the drug authorization request form and include supporting records per the Prior Authorization Process.

Overview: PA, ST, QL and SP utilization management controls

Providers should expect utilization management controls across the formulary: certain drugs require prior authorization (PA), some require step therapy (ST), many have quantity limits (QL), and specialty drugs are designated SP with additional handling requirements.

• Check the Requirements/Limits column for PA, ST, QL, SP, and LA indicators before prescribing.
• Lack of required PA or ST may result in noncoverage.

Mail‑service dispensing: up to 90‑day supply where allowed by plan

Mail‑service pharmacy can furnish up to a 90‑day supply of certain medications for members eligible under their group benefits plan; providers may advise patients to use mail service where permitted by benefits.

• Confirm member group benefits permit mail‑service 90‑day supply prior to prescribing.
• Advise patients that mail‑service may improve adherence and cost-efficiency when available.

Examples: prior authorization plus quantity limits (e.g., DIFICID, fidaxomicin)

Some specific products are subject to both prior authorization and explicit quantity limits (examples in the formulary include DIFICID oral suspension: PA; 100 mL per fill, and fidaxomicin: PA; 20 tabs per fill).

• When prescribing DIFICID or fidaxomicin confirm PA is obtained and that dispensing does not exceed the per‑fill QL shown on the formulary.

Specialty drugs: PA, SP, LA and QL commonly required

Numerous specialty and oncology drugs are designated with PA and SP and often have additional limits such as LA (limited access) and QL; prescribers must follow specialty pharmacy dispensing and authorization requirements for these agents.

• Confirm whether a specialty pharmacy (SP) is required and submit PA per formulary instructions before dispensing.
• Be aware of LA flags indicating limited availability at specific pharmacies.

Multiple UM flags: verify PA, ST and QL per drug

The formulary shows many entries with multiple utilization management flags — including PA, ST, and QL — meaning prescribers should verify each drug’s specific requirements before prescribing to avoid coverage delays or denials.

• Review the Requirements/Limits entry for each drug; do not assume uniform controls across a therapeutic class.
• Submit required documentation via the PA process when multiple flags are present.

Age‑based prior authorization requirements

Some products have age‑based prior authorization requirements (for example, erythromycin ethylsuccinate oral suspension and certain injectable antipsychotics list PA tied to specific age thresholds).

• Confirm age‑specific PA requirements in the Requirements/Limits column (e.g., PA for Age ≤17 or PA for Age ≥19) and document patient age on PA submissions.

Common UM indicators: PA, SP, LA, QL, ST appear across entries

The formulary uses common utilization modifiers — PA (prior authorization), SP (specialty), LA (limited access), QL (quantity limit), and ST (step therapy) — across many entries; always check the drug line for applicable indicators before prescribing.

• Interpret the abbreviations using the table legend at the beginning of the formulary.
• Ensure submitted documentation addresses the specific modifier(s) shown for the requested product.

Quantity limits enforced as amounts per time period (per day/28/365)

Quantity limits are enforced and specified as counts per time period (examples include limits per day, per 28 days, or per 365 days); prescribers must ensure prescriptions conform to the QL or request an exception via PA.

• Examples of QL formats: '4 per 1 day', '8 per 28 days', '28 per 365 days', '10 per 30 days'.
• If a longer or larger supply is needed, submit a QL exception with medical necessity documentation.

Authorization and limits present on formulary drug lines

Formulary listings routinely show authorization and limit flags (PA, QL, ST, SP, LA); verify the drug line’s Requirements/Limits before prescribing to determine if prior authorization or other restrictions apply.

• Drugs marked 'PA' require prior approval before dispensing.
• Drugs marked 'ST' may require documented trials of specified agents prior to coverage.

Specialty product controls: SP designation and per‑fill QLs

Certain specialty injectables and opioid antagonists are designated SP and have per‑fill quantity limits (examples include SUBLOCADE and VIVITROL); prescribers must follow specialty dispensing and QL rules for these agents.

• SUBLOCADE: Requirements / Limits = PA; SP; QL (0.5 per 28 days).
• VIVITROL: Requirements / Limits = SP (verify PA if indicated for specific products).

Formulary requirement codes must be interpreted and followed

Formulary entries indicate requirement codes (PA, SP, QL, LA, ST) — prescribers must interpret these codes using the table legend and follow the corresponding authorization or dispensing procedures.

• Refer to the formulary legend at the beginning of the table to interpret symbols and abbreviations.
• Address the specific requirement code(s) in any PA submission.

Injectable/long‑acting products: age‑based PA and specified QL frequencies

Many long‑acting injectable products include prior authorization tied to pediatric age thresholds (Age ≤17) and specify quantity frequencies (e.g., INVEGA SUSTENNA with PA for Age ≤17 and QL per 28 days); include patient age and dosing frequency in PA documentation.

• Document patient age on PA submissions for products with age‑based PA.
• Include requested dosing schedule to match QL entries (e.g., QL 0.75 per 28 days).

Prior authorization and quantity limits noted for multiple drugs (examples)

Multiple drugs in the formulary list prior authorization and quantity limits — prescribers should check specific drug entries (e.g., TRINTELLIX = PA; QL 1 per 1 day; trifluoperazine = PA for Age ≤17) and submit PA when indicated.

• TRINTELLIX: PA; QL (1 per 1 day).
• Trifluoperazine: PA for Age ≤17; QL (4 per 1 day).

Special program / limited‑access products require SP/LA/PA combinations

Some products are in special program or limited access categories and require combinations of SP, LA and PA (for example, XYWAV and ZURZUVAE show PA; SP; LA); failure to follow restricted access procedures may lead to denial.

• XYWAV: PA; SP; LA; QL (18 per 1 day).
• ZURZUVAE: PA; SP; QL (28 per 14 days).
• Verify dispensing location and specialty pharmacy requirements for LA items.

Formulary requirement codes summary: act on PA, SP, QL, LA, ST

The formulary consistently uses requirement codes (PA, SP, QL, LA, ST); prescribers must follow the indicated processes (e.g., obtain PA when marked) to ensure coverage.

• Always confirm and act on requirement codes present in the drug’s Requirements/Limits field.

Biologic dermatology agents: PA, SP and QL commonly required

Dermatology biologic entries frequently carry PA, SP, QL and sometimes ST requirements (examples include DUPIXENT and ADBRY); include indication, prior treatments, and dosing in PA submissions for biologics.

• DUPIXENT PEN 300 mg: PA; SP; QL (4 per 28 days).
• ADBRY: PA; SP; QL (4 per 28 days).

UM indicators in formulary segments: PA, SP, QL, LA frequent

Utilization management modifiers such as PA, SP, QL and LA appear widely across formulary segments; check the specific drug entry for required authorizations and limits before prescribing high‑cost or specialized products.

• Many Tier‑5 agents list PA; SP; QL (e.g., EMPAVELI = PA; SP; LA; QL 160 per 28 days).
• Confirm prior authorization requirements and specialty pharmacy routing as applicable.

Legend reference: interpret PA/QL/ST/SP/LA codes using the table legend

Refer to the formulary table legend at the beginning of the document to interpret abbreviations and symbols used in Requirements/Limits (PA, QL, ST, SP, LA, ACA, OTC).

• The legend explains the meaning of PA, QL, ST, SP, LA and other codes used throughout the formulary.
• If uncertain, contact AvMed Customer Service for clarification.

Prior authorization and specialty pharmacy requirements for many medications

Numerous medications in the formulary require prior authorization and specialty pharmacy handling for coverage; confirm PA and SP requirements (and any QL) before prescribing to specialty products.

• High‑cost specialty drugs listed under Biotechnology frequently require PA; SP and QL (see specific drug rows).
• Coordinate with the required specialty pharmacy when PA is approved.

CGM devices: PA and QL on receivers/sensors (document device and need)

Continuous glucose monitor devices and sensors (e.g., Dexcom G6/G7) are listed with prior authorization, CGM designation and specific quantity limits (e.g., receivers 1 per 365 days, sensors 2–3 per 30 days), so include device type and justification in PA requests.

• DEXCOM G6 RECEIVER: PA; CGM; QL (1 per 365 days).
• DEXCOM G6 SENSOR: PA; CGM; QL (3 per 30 days).
• State device model and clinical need on PA submissions.

Examples: PA plus QL for selected antidiabetic agents (MOUNJARO, OZEMPIC)

Selected agents include both prior authorization and specific quantity limits — for example, MOUNJARO requires PA and has QL (2 per 28 days); OZEMPIC oral tablet 1.5 mg requires PA and has QL (30 per 365 days).

• MOUNJARO: Requirements / Limits = PA; QL (2 per 28 days).
• OZEMPIC ORAL TABLET 1.5 mg: Requirements / Limits = PA; QL (30 per 365 days).

Specialty and limited‑access drugs: PA plus SP/LA often required

Several specialty products are subject to PA plus SP and limited‑access restrictions (e.g., BYLVAY shows PA; SP; LA; QL varying by strength, and CIMZIA shows PA; SP; QL 2 per 28 days); follow the specialty pharmacy and PA instructions to avoid denial.

• BYLVAY: PA; SP; LA; QL (varies by strength).
• CIMZIA: PA; SP; QL (2 per 28 days).

Step therapy flags: ST designated products require documented trials

Some products are explicitly designated as step therapy (ST) on the formulary (for example, PANCREAZE and PERTZYE are listed with ST); document prior required trials or submit a PA for exception.

• PANCREAZE — Requirements / Limits = ST.
• PERTZYE — Requirements / Limits = ST.
• Provide documentation of trials of required agents when requesting coverage for ST‑designated drugs.

Biotechnology drugs: expect PA, SP and QL requirements

Many biotechnology drugs require prior authorization, specialty pharmacy designation and quantity limits; prescribers should submit complete clinical documentation and route to the appropriate specialty pharmacy when PA indicates SP.

• Biotech examples: ARANESP, GRANIX, ACTEMRA, ADALIMUMAB variants — many list PA; SP; QL.
• Include diagnosis, prior therapy history and dosing rationale in PA submissions for biotech products.

ACA vaccine flags and age‑based PA for some vaccines

Several vaccine entries are marked 'ACA' indicating Affordable Care Act–related coverage requirements; verify ACA preventive coverage status and any age‑based PA listed on the formulary before ordering.

• Examples: ABRYSVO lists PA for Age ≤49; COMIRNATY and SHINGRIX are marked ACA.
• Follow formulary notes for vaccine age or ACA coverage conditions.

Biotech/rheumatology agents: PA, SP and QLs expected

Many rheumatology and biotech products are assigned PA, SP and QL; prescribers must include indication, prior treatment, and dosing to support PA requests (examples include ACTEMRA, ADALIMUMAB, ENBREL with PA; SP; QL entries).

• ACTEMRA ACTPEN — PA; SP; QL (3.6 per 28 days).
• ADALIMUMAB variants — PA; SP; QL (2 per 28 days).

Step therapy examples: ST designation requires prior trials or PA

Step therapy examples appear in the formulary (e.g., RASUVO and certain oral products designated ST); prescribers should document trials of required agents or request PA for exceptions.

• RASUVO (PF) = ST; prescribers must follow step prior requirements or request prior authorization for exception.

OB/GYN drugs: PA and QL present on select products

Some OB/GYN products carry prior authorization or quantity limits (for example, CRINONE and DUAVEE require PA; MYFEMBREE requires PA and QL 1 per 1 day; ORIAHNN has PA and QL 2 per 1 day).

• MYFEMBREE: Requirements / Limits = PA; QL (1 per 1 day).
• ORIAHNN: Requirements / Limits = PA; QL (2 per 1 day).

Specialty ophthalmic drugs: PA, SP and specified QL intervals

Several specialty ophthalmic drugs are subject to prior authorization, specialty pharmacy requirements, and explicit quantity limits expressed per day/28/365 days (examples include CYSTADROPS, OXERVATE and XDEMVY).

• CYSTADROPS: PA; SP; QL (20 per 28 days).
• OXERVATE: PA; SP; QL (56 per 720 days).
• XDEMVY: PA; SP; QL (10 per 365 days).

Pulmonary/specialty respiratory agents: PA, SP, LA and QL enforcement

Respiratory and specialty pulmonary agents commonly have utilization controls including PA, SP, LA and QL (for example, ADEMPAS and ALYFTREK entries show PA; SP; QL); ensure PA and any specialty dispensing routes are followed.

• ALYFTREK: Requirements / Limits = PA; SP; QL (2–3 per 1 day depending on formulation).
• Confirm PA and specialty pharmacy requirements for pulmonary specialty agents prior to prescribing.

Tier‑5 specialty drugs: expect PA, SP, LA and QL requirements

Many Tier‑5 (specialty/high‑cost) drugs list multiple authorization requirements including PA, SP, LA and QL (for example, OPSUMIT lists PA; SP; LA; QL 1 per 1 day); prescribers must follow the coverage pathway indicated on each formulary line.

• OPSUMIT: Requirements / Limits = PA; SP; LA; QL (1 per 1 day).
• Verify specialty pharmacy routing and any limited‑access pharmacy constraints before submitting a PA.