CurrentAvMedPolicy N/A

Xadago (safinamide) prior authorization

This form governs prior authorization and step-edit requirements for the pharmacy coverage of Xadago (safinamide) for AvMed members; it affects prescribing providers seeking coverage for this medication.

Policy Summary

PayerAvMed

PolicyXadago (safinamide) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a completed prior authorization form to 1-305-671-0200 including member, prescriber, and drug information; provide documentation (chart notes or pharmacy claims) verifying prior MAO-B therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2017-10-19P&T approval date

>=30 daysrequired trial duration

1failed MAO-B agents required

50→100 mgdosing escalation

Coverage Criteria for Xadago (safinamide)

Initial Authorization Criteria

Covered when ALL of the following are met

Initial approval: Member must have tried and failed at least 30 days of therapy with ONE of the following: selegiline or rasagiline (verified by chart notes or pharmacy paid claims).>= 30 days

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Documentation including lab results, diagnostics, and/or chart notes must be provided or the request may be denied.

Use of samples to initiate therapy does not satisfy the plan's step-edit or prior authorization requirements. This policy requires documented trial and failure of a formulary MAO-B agent (selegiline or rasagiline) verified by chart notes or pharmacy paid claims; initiating treatment with free or promotional samples alone will not meet that requirement.

Initial Therapy

Initial authorization requirements

Policy Summary

PayerAvMed

PolicyXadago (safinamide) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Step therapy requirement: Trial and failure of at least 30 days of ONE of: selegiline or rasagiline (verified by chart notes or pharmacy paid claims).>=30 days

Samples do not satisfy this requirement; prior therapies will be verified through pharmacy paid claims or submitted chart notes.

Step Therapy Requirements

Step	Requirement	Duration	Documentation	Coverage
1	Trial and failure of at least one MAO-B inhibitor (selegiline or rasagiline)	>= 30 days	Verified by chart notes or pharmacy paid claims; use of samples does not meet requirement	Covered with criteria

Coding and Trial Duration

inv-03: Required trial duration

Required trial duration>= 30 days

Minimum qualifying agentsTrial of at least ONE MAO-B inhibitor (selegiline or rasagiline)

Verification methodsPrior therapy must be verified by chart notes or pharmacy paid claims

Samples policyUse of samples to initiate therapy does not meet step edit/preauthorization criteria

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required using the AvMed Pharmacy Prior Authorization/Step-Edit Request form. Fax the completed form to 1-305-671-0200 with complete member, prescriber, and drug information. Provide accurate phone and fax numbers on the form to avoid delays; no additional phone calls will be necessary if all required information is complete and legible.

Fax completed prior authorization form to 1-305-671-0200
Include complete member, prescriber, and drug information (member name, AvMed ID #, DOB)
Ensure phone and fax numbers provided on form are accurate

Documentation Required

Provider Identification and Signature

The prescribing physician must sign and clearly print their name on the prior authorization request. Preprinted signature stamps are not valid. Include prescriber contact details (office contact, phone number, fax number) and DEA or NPI number to ensure the request is processed.

Prescriber signature and printed name required (no preprinted stamps)
Include prescriber phone, fax, office contact name, and DEA or NPI #
Provide date of signature

Documentation Required

Supporting Documentation Required

All clinical criteria selected on the form must be supported with documentation. Provide relevant chart notes, laboratory results, diagnostic reports, and prior treatment history (including pharmacy paid claims) to substantiate each checked criterion. Incomplete, incorrect, or illegible information — or lack of required supporting documentation — may delay review or result in denial of the authorization.

Provide chart notes or pharmacy paid claims verifying prior therapies
Attach lab results and diagnostic reports as applicable
Incomplete/illegible submissions may be delayed or denied

Background

Background information specific to clinical rationale is not provided on the form beyond dosing and step-edit verification requirements. The form contains dosing guidance—start at 50 mg once daily with possible escalation to 100 mg once daily after two weeks—and focuses primarily on administrative prior authorization and step therapy checks, including verification of prior therapies and the requirement that documentation (lab results, diagnostics, and/or chart notes) be submitted to support checked criteria.