AUVI-Q (epinephrine)

AUVI-Q (epinephrine)

Self-Administration - Injection

Indications for Prior Authorization:

Indicated in the emergency treatment of allergic reaction (Type 1) including anaphylaxis to stinging insects (e.g., order Hymenoptera, which includes bees, wasps, hornets, yellow jackets, and fire ants) and biting insects (e.g., triatoma, mosquitos) allergen immunotherapy, foods, drugs, diagnostic testing substances (e.g., radiocontrast media) and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis

Coverage Criteria:

1. For diagnosis of emergency treatment of allergic reactions (Type 1):

• Dose does not exceed weight-based dosing, AND
• One of the following:
  • Trial and failure of both generic epinephrine autoinjector and Epipen ® products, OR
  • Documentation provided confirming patient or patient’s caregivers are unable to utilize alternative epinephrine autoinjector devices (e.g., Epipen ®, generic epinephrine autoinjector) due to significant visual, physical, or functional impairment, OR
  • Documentation provided confirming patient’s weight is between 7.5 to 15 kg

Coverage Duration:

• 1 year

Dosing:

• Selection of the appropriate dosage strength (Auvi-Q 0.3 mg, Auvi-Q 0.15 mg, or Auvi-Q 0.1 mg) is determined according to body weight:
  • Patients greater than or equal to 30 kg (approximately 66 pounds or more): Auvi-Q 0.3 mg
  • Patients 15 to 30 kg (33 to 66 pounds): Auvi-Q 0.15 mg
  • Patients 7.5 to 15 kg (16.5 to 33 pounds): Auvi-Q 0.1 mg

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:

• Anvi-Q is intended for immediate administration in patients who are determined to be at increased risk for anaphylaxis, including individuals with a history of anaphylactic reactions.
• Anaphylactic reactions may occur within minutes after exposure and consist of flushing, apprehension, syncope, tachycardia, thready or unobtainable pulse associated with a fall in blood pressure, convulsions, vomiting, diarrhea and abdominal cramps, involuntary voiding, wheezing, dyspnea due to laryngeal spasm, pruritus, rashes, urticaria or angioedema.
• Auvi-Q is intended for immediate self-administration as emergency supportive therapy only and is not a substitute for immediate medical care.
• It is not known if Auvi-Q is safe and effective in children who weight less than 7.5 kg (16.5 pounds)

Policy Updates:

• 10/19/2021 – Policy update.  Updated criteria on patient’s weight based on package insert.

References:

• Auvi-Q [package insert], Kaleo, Inc. Richmond, VA. November 2020