SELF-ADMINISTRATION - INJ
Indications for Prior Authorization:
Emergency treatment of allergic reactions (Type 1) including anaphylaxis to stinging insects and biting insects, allergen immunotherapy, foods, drugs, diagnositc testing substances and other allergens, as well as idiopathic anaphylaxis or exericse-induced anaphylaxis.
Auvi-Q is intended for immediate self-administration as emergency supportive therapy only and is not a substitute for immediate medical care.
Patients must meet the following criteria for the indication(s) above:
- Patients must try and fail both Epinephrine Autoinjector and EpiPen® products, OR
- Patient or the patient's caregivers are unable to utilize the alternatives epinephrine autoinjector devices (e.g. EpiPen®, generic epinephrine autoinjector) due to significant visual, physical or functional impairment as supported by chart note documentation, OR
- Chart notes are provided, documenting the patient's current weight is less than 15 kg
- Patients greater than or equal to 30kg: 0.3mg
- Patients 15-30kg: 0.15mg
- Patients 7.5-15kg: 0.1mg
Last review date: October 15, 2019