CurrentAvMedPolicy N/A

Zyflo (zileuton) and zileuton extended-release prior authorization

Prior authorization form and coverage criteria for Zyflo (zileuton) and zileuton ER for AvMed members; applies to prescribers seeking pharmacy benefit coverage for these drugs.

Policy Summary

PayerAvMed

PolicyZyflo (zileuton) and zileuton extended-release prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed pharmacy prior authorization form with chart notes documenting required therapy trials and failures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12min age

600 mgmax qty/day

>=3 monthsICS/LABA trial

30 daysLTRA trials

Coverage Criteria

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Age: Member must be 12 years of age or older>=12 years

Diagnosis: Member must have a confirmed diagnosis of asthma

ICS/LABA trial: Member must have trial and failure of a combination inhaled corticosteroid/long-acting beta-2 agonist product (e.g., Symbicort, Advair) for at least 3 months with chart notes documenting therapy failures>=3 months

Examples: Symbicort, Advair; chart notes must be submitted

Policy Summary

PayerAvMed

PolicyZyflo (zileuton) and zileuton extended-release prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed pharmacy prior authorization form with chart notes documenting required therapy trials and failures.

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.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The prescribing physician must sign and clearly print their name (preprinted stamps are not valid) on the pharmacy PA form and fax it to AvMed at 1-305-671-0200. All requested information (including phone and fax numbers) must be complete, correct, and legible; incomplete, incorrect, or illegible forms or missing documentation (labs, diagnostics, chart notes) can delay or result in denial of authorization.

Fax: 1-305-671-0200
Prescribing physician signature required (no preprinted stamps)
Ensure phone and fax numbers are provided and legible

Step Therapy

Step Therapy Requirements

Step therapy requirements must be met before approval. ALL clinical step criteria below must be documented with chart notes or pharmacy claims showing trials and failures.

Trial and failure of an inhaled corticosteroid/long-acting beta-2 agonist combination (e.g., Symbicort, Advair) for ≥ 3 months — chart notes documenting failure required
30-day trial and failure of BOTH montelukast AND zafirlukast — chart notes documenting failures required
Use of drug samples to initiate therapy does not satisfy step-edit/preauthorization requirements

Documentation Required

Supporting Documentation Required

Supporting documentation is required to substantiate all criteria and may include chart notes, lab results, diagnostics, and pharmacy paid claims. Authorization may be delayed or denied if documentation is missing. The following must be provided as applicable: member age, confirmed diagnosis, dosing schedule, length of therapy, weight, ICD code, and evidence of prior therapy trials/failures.

Member must be ≥ 12 years of age and have a confirmed diagnosis of asthma
Provide drug form/strength, dosing schedule, length of therapy, date, and maximum quantity requested
Maximum quantity limit: 600 mg daily; 4 tablets per day
Previous therapies will be verified through pharmacy paid claims or submitted chart notes

Documentation Required

Form Completion and Documentation

Complete and legible form completion is essential. If information is incomplete, incorrect, or illegible, or if required supporting documentation (labs, diagnostics, chart notes) is not provided, the authorization process can be delayed or the request denied.

Ensure all fields on the PA form are completed; prescriber signature required
Missing documentation impacts decision and may result in denial

Initial Therapy Criteria

Initial approval — Approval requires meeting all criteria listed below

Approval requires meeting all criteria listed below.

Age: Member >= 12 years>=12 years

Diagnosis: Confirmed asthma diagnosis

ICS/LABA trial: Failure of combination inhaled corticosteroid/long-acting beta-2 agonist for >=3 months with chart documentation of therapy failures>=3 months

Examples: Symbicort, Advair; chart notes will be verified

Leukotriene antagonist trials: 30-day trial and failure of BOTH montelukast and zafirlukast with documentation of therapy failures30 days each

Previous therapies may be verified through pharmacy paid claims or submitted chart notes

Step	Required prior therapy	Minimum trial duration	Documentation required
3
Zafirlukast
30 days
Chart notes documenting therapy failure; prior therapies may be verified via pharmacy paid claims or submitted chart notes.

OpenPayer

Zyflo (zileuton) and zileuton extended-release prior authorization

Coverage Criteria

Coding

Provider Actions & Requirements

Background

Definitions

Initial Therapy Criteria

Step Therapy Requirements

Quantity Limits