CurrentAvMedPolicy N/A

Topical corticosteroid pharmacy prior authorization and step-edit request

Form and criteria governing prior authorization and step-therapy for topical corticosteroid prescriptions for AvMed members; applies to prescribers requesting coverage for listed topical steroid products.

Policy Summary

PayerAvMed

PolicyTopical corticosteroid pharmacy prior authorization and step-edit request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization via fax to 1-305-671-0200 with a handwritten prescriber signature and required supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4potency tiers listed

>=3required prior failures

faxsubmission method

requiredsignature

Coverage criteria and clinical requirements

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.

Primary requirements: Prescriber completed form with required fields and handwritten signature; all requested documentation provided; member has tried and failed 30 days of therapy with at least THREE of the listed topical therapies (from the low, medium, high, or very high potency lists), verified by chart notes or pharmacy paid claims.at least 3 prior therapies of 30 days each

To support each line checked, all documentation, including lab results, diagnostics, and/or chart notes, must be provided or request may be denied. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. This policy requires documented prior trials and supporting documentation for step-therapy; initiating treatment with manufacturer or office samples does not satisfy the requirement to demonstrate prior use or failure of listed topical therapies.

The policy does not list any additional not medically necessary conditions beyond the explicit statement that samples cannot be used to meet step-edit or preauthorization requirements. No other NMN criteria are specified in the form; providers must follow the stated step-therapy and documentation requirements for coverage consideration.

Diagnosis, trial durations, and coding fields

Diagnosis codes (form field)ICD-10

ICD Code, if applicable (field on form)

inv-05: Required trial duration

Required trial duration30 days per prior therapy trial

Documentation of durationEach prior therapy must be documented by chart notes or pharmacy paid claims for 30 days

Verification methodPrevious therapies will be verified through pharmacy paid claims or submitted chart notes

inv-06: Number of prior therapies required

Number of prior therapies requiredAt least 3 distinct topical therapies

Therapy coverageTrials may be from any potency tier listed (Low, Medium, High, Very High)

DocumentationFailures must be documented by chart notes or pharmacy paid claims

What providers must submit and watch for

Prior Authorization

Submission and signature requirement

Prior authorization requests must be submitted via fax to 1-305-671-0200. The prescribing physician must sign and clearly print their name on the request (preprinted stamps are not valid). All other information may be filled in by office staff. No additional phone calls will be necessary if all information (including phone and fax numbers) on this form is correct.

Fax: 1-305-671-0200
Prescriber signature required (no preprinted stamps)
Include complete phone & fax contact information

Note

Formulary / medical necessity

If a drug is non-formulary on a member's plan, documentation of medical necessity must be provided to support the request. Coverage may vary by plan — verify formulary status before submitting.

Non‑formulary drugs require medical necessity documentation
Verify member's plan formulary status before submission

Step Therapy

Step therapy requirement

Member must have tried and failed 30 days of therapy with at least three listed topical therapies (from the low, medium, high, or very high potency tiers) as verified by chart notes or pharmacy paid claims. Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Requirement: 30 days trial each, and at least THREE different listed topical therapies
Verification via chart notes or pharmacy paid claims
Samples do not meet step edit/authorization criteria

Documentation Required

Required supporting documentation

All documentation supporting the criteria selected must be provided with the request. This includes relevant lab results, diagnostics, and chart notes. Previous therapies will be verified through pharmacy paid claims or submitted chart notes; failure to provide adequate documentation may result in denial.

Provide lab results, diagnostics, and chart notes to support each checked criterion
Include evidence of prior therapies (chart notes or pharmacy paid claims)
Incomplete supporting documentation may result in denial

Denial Risk

Incomplete or insufficient documentation — denial risk

If the information provided is incomplete, incorrect, or illegible, the authorization process can be delayed or the request may be denied. Failure to provide documentation (lab results, diagnostics, chart notes) to support each line checked may result in denial.

Incomplete/illegible submissions can delay processing or lead to denial
Each checked criterion must be supported by documentation or claim history

Clinical background

Topical corticosteroids are available in multiple potency tiers and are commonly used for dermatologic inflammatory conditions. This prior authorization/step-edit form catalogs agents by potency and requires that the prescriber complete the form with required fields and a handwritten signature. For initial approval, the member must have tried and failed prior topical therapies as documented by chart notes or pharmacy paid claims; supporting documentation must be provided and prior therapies will be verified. The form also notes administrative requirements (for example, incomplete or illegible submissions can delay authorization) and that non-formulary drugs will require documentation of medical necessity.

Potency tiers and definitions

inv-15: Low, Medium, High, Very High potency topical corticosteroids as listed on the form

Low potencyCapex (fluocinolone) 0.01% shampoo; Texacort (hydrocortisone) 2.5% solution

Medium potencybetamethasone valerate 0.12% foam (generic Luxiq); clocortolone pivalate 0.1% cream (generic Cloderm); Cordran (flurandrenolide) 4 mcg/sqcm tape; flurandrenolide 0.05% cream; fluticasone 0.05% lotion

High potencyamcinonide 0.1% cream/lotion/ointment; desoximetasone 0.05% cream/gel/ointment; calcipotriene 0.005%-betamethasone 0.064% ointment/suspension; diflorasone 0.05%; fluocinonide 0.1%; triamcinolone spray

Very High potencyclobetasol propionate 0.05% foam/emulsion/shampoo; Impoyz (clobetasol) 0.025% cream; halobetasol 0.05% (listed on form)

Prior therapy requirements for initial authorization

Prior therapy trials

Initial authorization requires documented failure of prior topical therapies:

Prior therapy trials: Member has tried and failed 30 days of therapy with at least THREE of the listed topical therapies across potency tiers, verified by chart notes or pharmacy paid claims.at least 3 therapies, each 30 days

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

Step	Requirement
1	Failure of at least three listed topical therapies (each with a 30‑day trial) documented by chart notes or pharmacy paid claims prior to approval