CurrentAnthemPolicy N/A

Prior Authorization for Concurrent Benzodiazepine and Opioid Therapy

This document governs prior authorization (PA) requirements for members receiving concurrent benzodiazepine and opioid therapy for Anthem-managed Indiana programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging) and applies to prescribing providers requesting PA.

Policy Summary

PayerAnthem

PolicyPrior Authorization for Concurrent Benzodiazepine and Opioid Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a complete prior authorization form and fax to the Prior Authorization of Benefits Center (retail: 844-864-7860; medical injectable: 888-209-7838).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysConcomitant therapy threshold within a 180-day period requiring PA

844-864-7860Retail PA fax

888-209-7838Medical injectable PA fax

Wet signatureSignature requirement

ReviewedINSPECT report

Policy Summary

PayerAnthem

PolicyPrior Authorization for Concurrent Benzodiazepine and Opioid Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a complete prior authorization form and fax to the Prior Authorization of Benefits Center (retail: 844-864-7860; medical injectable: 888-209-7838).

SourceLink

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PA Criteria and Required Documentation

Prior authorization requests for concurrent benzodiazepine and opioid therapy must include documentation of diagnoses, prior therapies and utilization, prescriber coordination, plans for continuation or withdrawal, and prescriber attestation and signature.

ALL of the following

ALL of the following
- Provide member diagnosis(es) for benzodiazepine therapy.
- Provide member diagnosis(es) for opioid therapy.
ALL of the following
- List prior therapies attempted for each diagnosis, including drug name and dosage regimen.
- Provide dates of utilization for each prior therapy and reason for discontinuation if applicable.
ALL of the following
- Indicate whether benzodiazepine therapy will be continued; if not, provide a benzodiazepine withdrawal plan.
- Indicate whether opioid therapy will be continued; if not, provide an opioid withdrawal plan.
ALL of the following
- Identify requested opioid agent(s) and/or benzodiazepine(s) with prescriber name, quantity, and dosage regimen/duration.
ALL of the following
- If different prescribers are involved, state whether the other prescriber(s) are aware of the request for concurrent therapy.
- State whether other prescriber(s) have been consulted about risks of concurrent therapy and whether all prescribers agree that continuing concurrent therapy is warranted given the risks.
ALL of the following
- Complete all sections of the PA form in its entirety; incomplete forms will be returned.
- Fax the completed form to the Prior Authorization of Benefits Center (retail: 844-864-7860; medical injectable: 888-209-7838).
ALL of the following
- Prescriber must attest that the member's INSPECT report has been evaluated and will continue to be evaluated regularly (do not attach INSPECT report).
- Prescriber must attest that the member has been educated on risks of concurrent therapy and accepts those risks; if applicable, attest that other prescribers agree to pursue concurrent therapy.
- Provide original prescriber signature; electronic or stamped signatures are not accepted.

ALL of the following

PA is required when a new opioid is to be used concurrently with benzodiazepines and the concurrent use exceeds seven days within a 180-day period.
PA is required when a new benzodiazepine is to be used concurrently with opioids and the concurrent use exceeds seven days within a 180-day period or exceeds established concurrent therapy quantity limits.

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Required for Concurrent Therapy

PA is required when concurrent use of a new opioid with benzodiazepines exceeds seven days within any 180-day period, and when a new benzodiazepine is to be used concurrently with opioids exceeding seven days within a 180-day period or exceeding established concurrent therapy quantity limits.

Concurrent therapy PA threshold: >7 days within 180 days
See Sedative Hypnotics Benzodiazepine PA criteria for quantity limits

Documentation Required

Submission Instructions and Completeness Requirement

Complete the form in its entirety. Incomplete requests will be returned. Fax the completed form and supporting documentation to the Prior Authorization of Benefits Center: 844-864-7860 (retail) or 888-209-7838 (medical injectable). For assistance contact the Provider Help Desk at one of the following numbers: 866-408-6132 (Hoosier Healthwise), 844-533-1995 (Healthy Indiana Plan), 844-284-1798 (Hoosier Care Connect), or 833-569-4739 (Indiana PathWays for Aging). Required form fields include patient Medicaid number, patient name, date of birth, prescriber's name, prescriber's IN license number, specialty, prescriber's NPI, return fax and phone, and indication if retroactive PA is requested (include dates of service). Submit retroactive PA requests for dates of service prior to eligibility determination (outside the 30-calendar-day current request window) separately from current PA requests.

Fax numbers: 844-864-7860 (retail); 888-209-7838 (medical injectable)
Provider Help Desk: 866-408-6132 (Hoosier Healthwise); 844-533-1995 (Healthy Indiana Plan); 844-284-1798 (Hoosier Care Connect); 833-569-4739 (Indiana PathWays for Aging)
All sections of the form must be completed or the request will be returned
Include dates of service for retroactive PA separately (prior to 30 calendar days of submission)

Documentation Required

Attestation and Signature Requirement

The prescriber must complete the attestation and provide a wet (ink) signature. Electronic or stamped signatures will not be accepted. The attestation must confirm review of the member's INSPECT report (do not attach the INSPECT report), education of the member on risks of concurrent benzodiazepine and opioid therapy, consultation with other prescribers when applicable, and acknowledgment of the risks including respiratory depression, coma, and death.

Prescriber signature: wet (ink) signature required; electronic or stamped signatures are not accepted
Attestation must state INSPECT report has been evaluated (do not attach the report)
Attestation must confirm patient education on risks and consultation with other prescribers when applicable

Note

Coordination Among Prescribers

If the opioid and benzodiazepine prescribers are different, document whether other prescribers are aware of and have been consulted about the concurrent therapy and that all prescribers involved agree that continuing concurrent therapy is warranted given the risks.

Document whether other prescriber(s) are aware of the concurrent therapy: Yes / No
Document that other prescriber(s) were consulted about risks and concur with continuation when applicable

Key Definitions

Concurrent therapy definition

Definition of concurrent therapy requiring PAConcurrent benzodiazepine and opioid therapy that exceeds seven days of overlapping use within a 180-day period or that exceeds established benzodiazepine/opioid concurrent therapy quantity limits triggers prior authorization.

Trigger scenarios(1) New opioid used concurrently with benzodiazepine exceeding 7 days in 180 days; (2) New benzodiazepine used concurrently with opioid exceeding 7 days in 180 days; (3) Exceeding established quantity limits for concurrent therapy.

Related criteria referenceSee Sedative Hypnotics Benzodiazepine PA criteria for specific quantity limits when applicable.

State prescription monitoring program (INSPECT)

INSPECT report requirementPrescriber must evaluate the member's INSPECT (state prescription monitoring program) report and continue to evaluate it on a regular basis; do not attach the INSPECT report to the PA request.

AttestationPrescriber must attest on the PA form that the INSPECT report has been reviewed and continues to be monitored (per IC 35-48-7-11.1).

Do not attachExplicit instruction: DO NOT attach a copy of the INSPECT report to the prior authorization request.

OpenPayer

Prior Authorization for Concurrent Benzodiazepine and Opioid Therapy

Prior Authorization Criteria

Coding and Thresholds

Provider Submission Requirements and Actions

Key Definitions