CurrentArizona Complete HealthPolicy AZ.CP.PMN.1009

Clinical Policy: SABG Drug List Exception Requests

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.

Policy Summary

PayerArizona Complete Health

PolicyClinical Policy: SABG Drug List Exception Requests

Policy CodePolicy AZ.CP.PMN.1009

Change TypeNo material clinical or coverage changes

Effective DateOct 1, 2019

Next Review DateFeb 25, 2025

Key ActionSubmit prior authorization with documentation demonstrating SUD or withdrawal indication and trials of preferred alternatives.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial & continueddistinct approval pathways described

up to 3 monthsinitial approval length

6 monthscontinued therapy length

12 monthsSABG eligibility timeframe

Coverage Criteria for SABG Non‑PDL or Brand Drugs

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Initial Approval Criteria for Brand or Non‑Formulary (Non‑PDL) Drugs

Initial Approval — Covered when ALL of the following are met

Initial Approval: 1. Prescribed indication is either for a Substance Use Disorder (including alcohol, opioid, benzodiazepine, stimulant or other drug use disorder) or for supportive treatment of withdrawal symptoms; 2. Prescribed indication is FDA-approved or supported by standard pharmacopeias or treatment guidelines; 3. Prior trials: if there are at least three preferred alternatives, history of therapeutic failure, contraindication, or intolerance to at least three preferred alternatives documented in pharmacy claims; if fewer than three preferred alternatives exist, history of therapeutic failure, contraindication, or intolerance to ALL preferred products documented in pharmacy claims; 4. If there are no preferred formulary alternatives for the requested drug, brand-specific criteria apply (see children); 5. Dose requested does not exceed the FDA‑approved maximum recommended dose for the relevant indication and health plan daily quantity limit, OR the dose is supported by practice guidelines or peer‑reviewed literature for relevant off‑label use with supporting evidence submitted; Approval duration: duration of request or 3 months (whichever is less)

Continued Therapy Criteria for Brand or Non‑PDL Drugs

Continued Therapy — Covered when ALL of the following are met

Continued Therapy: 1. Member is either currently receiving the medication via the Centene benefit OR has previously met initial approval criteria; 2. Member is responding positively to therapy; 3. If request includes a dose increase, the new dose does not exceed the FDA‑approved maximum recommended dose and health plan approved daily quantity limit, OR the new dose is supported by practice guidelines or peer‑reviewed literature for the relevant off‑label use (prescriber must submit supporting evidence); Approval duration: 6 months

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

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

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

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

Key Terms

PDL — Preferred drug list definition.

TermPDL (Preferred Drug List)

DefinitionPreferred drug list.

ContextUsed in this policy to identify formulary-preferred medications for Substance Use Disorder treatment; prior authorization and step-therapy requirements reference preferred alternatives on the PDL.

SABG — Substance Abuse Block Grant definition.

TermSABG (Substance Abuse Block Grant)

DefinitionSubstance Abuse Block Grant.

ContextFederal funding mechanism referenced in this policy for coverage of non-PDL or brand medications used to treat Substance Use Disorders; eligibility and documentation requirements specific to SABG-funded drugs are included in the policy.

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.

OpenPayer

Clinical Policy: SABG Drug List Exception Requests

Coverage Criteria for SABG Non‑PDL or Brand Drugs

Provider Requirements and Prior Authorization

Medications for Substance Use Disorder

Key Terms

Policy Background