Clinical Policy: SABG Drug List Exception Requests
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Defines medical necessity and documentation requirements for requesting non‑PDL or brand drugs funded by the Substance Abuse Block Grant (SABG) for Arizona Complete Health Medicaid members receiving SUD treatment.
No material clinical or coverage changes in this revision.
Coverage Criteria for SABG Non‑PDL or Brand Drugs
Initial Approval Criteria for Brand or Non‑Formulary (Non‑PDL) Drugs
Initial Approval — Covered when ALL of the following are met
Continued Therapy Criteria for Brand or Non‑PDL Drugs
Continued Therapy — Covered when ALL of the following are met
Coverage is limited to medications prescribed for Substance Use Disorder (SUD) or for supportive treatment of withdrawal symptoms. No diagnoses or indications beyond SUD or withdrawal support are eligible for coverage under this policy.
Provider Requirements and Prior Authorization
Prior Authorization Required
Prior authorization is required for brand-name or non‑PDL SABG drugs. Initial requests must demonstrate the indication is for substance use disorder (including alcohol, opioid, benzodiazepine, stimulant or other drug use disorders) or for supportive treatment of withdrawal symptoms, and that the prescribed indication is FDA‑approved or supported by standard pharmacopeias or treatment guidelines. Requests for brand or non‑PDL products must meet the policy's initial or continuation criteria.
- Prior authorization required for SABG non‑PDL or brand drugs
- Initial request must document SUD diagnosis or withdrawal-support indication
- Approval requires indication supported by FDA labeling or guideline/literature
Step Therapy / Trial Requirements
Documented evidence of therapeutic failure, contraindication, or intolerance to required preferred alternatives is required. If at least three preferred alternatives exist, provide pharmacy claim history showing failure/contraindication/intolerance to at least three. If fewer than three preferred alternatives exist, provide pharmacy claim history showing failure/contraindication/intolerance to all available preferred products. If no preferred formulary alternatives exist, support the request per brand/non‑PDL rules.
- If ≥3 preferred alternatives: trials or documented failures/contraindications/intolerances to at least THREE preferred alternatives
- If <3 preferred alternatives: trials or documented failures/contraindications/intolerances to ALL preferred products
- If no preferred alternatives: follow brand/non‑PDL documentation rules
Documentation Required to Avoid Denial
Provider must submit supporting clinical documentation to avoid denial. Include office chart notes, pharmacy claim history, lab results, treatment guidelines or literature, rationale for therapeutic failure or intolerance, and any attestation forms (e.g., FDA MedWatch submission when aversion/allergy to a generic is cited). For brand requests based on generic adverse reaction, prescriber must attest that an FDA MedWatch Form for allergic reactions has been submitted. For dose increases or off‑label dosing, include supporting practice guideline or peer‑reviewed literature. Incomplete requests missing these documents may be denied.
- Office chart notes and relevant lab results
- Pharmacy claim history demonstrating prior trials and outcomes
- Rationale and supporting evidence for therapeutic failure, intolerance, or contraindication
- Prescriber attestation and FDA MedWatch submission when applicable
- Supporting guidelines or peer‑reviewed literature for off‑label or above‑label dosing
Medications for Substance Use Disorder
Medications for SUD (general)
Key Terms
Policy Background
This policy governs exceptions to the SABG preferred drug list for medications used to treat Substance Use Disorders (including treatment of alcohol, opioid, benzodiazepine, stimulant, or other drug use disorders) and for supportive withdrawal care. Requests for brand-name or non‑PDL SABG-funded drugs require prior authorization and must meet the documented initial or continued therapy criteria, including demonstration of indication, trials of preferred alternatives where required, dose limits consistent with FDA labeling or guideline-supported rationale, and submission of supporting clinical documentation.
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