Avmed Request Form – Fill Out and Use This PDF

Avmed Request Form PDF Details

This form is used by AvMed members and their prescribing physicians to request access to medications outside the standard formulary. Two broad categories are covered: commercially available drugs that need a plan exception, and specialty or biologic medications administered in a physician's office or clinic. Knowing the scope, timelines, and documentation requirements helps you submit a complete request the first time.

Eligible Medications

The form applies to a wide range of specialty and clinically administered drugs. Examples of covered medications include:

• Abraxane and other chemotherapy agents used in an outpatient setting
• Xolair for patients with asthma or chronic spontaneous urticaria
• Intron A and genotype-specific HCV treatments including RNA-based therapies
• EQP-designated biologics requiring clinical documentation and step therapy review
• Self-administered specialty drugs dispensed through the AvMed specialty pharmacy program

Any medication requiring prior authorization due to formulary status, administration method, or clinical complexity can be submitted through this process. Contact your physician's office if you are unsure whether your medication qualifies.

Submission Timelines

AvMed reviews requests on two tracks based on clinical urgency:

• Routine submissions are processed within 14 calendar days. Use this track for stable, non-urgent medication needs where a short delay does not harm the patient.
• Urgent submissions are reviewed within 3 business days. The treating physician must confirm that the standard timeline poses a clinical risk to the patient.

Discuss the appropriate track with your prescribing physician before marking the form. Incorrectly flagging a routine request as urgent may trigger an additional verification step and slow the review process.

Required Documentation

Incomplete submissions are the leading cause of delays and denials. Prepare all of the following before submitting:

• Patient information: Full legal name, AvMed member ID, date of birth, and current diagnosis codes
• Medication details: Drug name, strength, dosage schedule, route of administration, and estimated treatment duration
• Physician details: Prescribing physician's full name, specialty, NPI number, office address, and direct contact number
• Supporting records: Current office notes describing the clinical rationale and current laboratory results where applicable

Lab results must reflect the patient's current clinical status. Older results from prior treatment periods may need to be supplemented with a physician note. Missing documentation restarts the review clock.

Delivery and Administration Settings

The form asks you to identify one of two administration pathways. Each follows a different approval and billing route:

• Physician-office administration: The drug is given in a clinic, hospital outpatient unit, or doctor's office. The physician or clinical staff manages ordering and administering the medication.
• Specialty pharmacy dispensing: The patient receives the drug from a specialty pharmacy and self-administers it at home. Requests take this route through the AvMed specialty pharmacy program.

Selecting the wrong delivery setting requires resubmission and resets the review timeline. Confirm the correct pathway with your physician before completing this section.

After Submission

Once received, AvMed sends a confirmation to the prescribing physician's office and, where applicable, to the specialty pharmacy. The review team may request additional information during the evaluation period. Keep a copy of all submitted documents for your records. If no decision arrives within the applicable timeline, contact AvMed provider services to check on your request status.