CurrentBlue Cross Blue Shield - MainePolicy N/A

Request for Prior Authorization - Benzodiazepine and Opioid Concurrent Therapy

This document is a prior authorization request form and requirements for members receiving concurrent benzodiazepine and opioid therapy under Anthem Blue Cross and Blue Shield programs listed for Indiana; it governs providers submitting PA requests for such concurrent therapy.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPrior authorization for concurrent benzodiazepine and opioid therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with prescriber signature and attestation, including diagnosis, prior therapies, dates of use, and withdrawal plan, faxed to the Prior Authorization of Benefits Center.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysconcurrent therapy duration threshold

180 dayslook-back period

3-4help desk contacts

Prior Authorization Coverage Criteria

PA submission criteria

Prior authorization will be considered when the required clinical information and prescriber attestation are provided. PA is required when a new opioid or benzodiazepine will be used concurrently and exceeds seven days within a 180‑day period.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPrior authorization for concurrent benzodiazepine and opioid therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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ALL of the following

Requests subject to PA
- Claim for a new opioid to be used concurrently with benzodiazepines and exceeding seven days within a 180-day period.
- Claim for a new benzodiazepine to be used concurrently with opioids and exceeding seven days within a 180-day period or exceeding established concurrent therapy quantity limits (see Sedative Hypnotics Benzodiazepine PA criteria).
Provide member diagnosis(es) for benzodiazepine and for opioid therapy, and list prior therapies attempted (include drug therapy and dosage regimens).
Include dates of utilization and reasons for discontinuation for prior therapies where applicable.
If continuing therapy is not planned, provide a withdrawal plan for benzodiazepine and/or opioid therapy.
If prescribers of the opioid(s) and benzodiazepine(s) are different, indicate whether the other prescriber(s) are aware of and have been consulted regarding the concurrent therapy and that all prescribers agree continuing concurrent therapy is warranted.
Attestation signed by the prescriber (electronic or stamped signatures are not accepted).
Attestation must state that the prescriber reviewed the member's INSPECT report (do not attach the report), educated the member on risks, consulted other prescribers if applicable, and acknowledges the risks including respiratory depression, coma, and death.

Provider Submission Requirements

Prior Authorization

Prior Authorization Required — Benzodiazepine and Opioid Concurrent Therapy

Submit a completed prior authorization form for benzodiazepine and opioid concurrent therapy. All sections of the form must be completed. Include patient identifiers, prescriber information, medication details (agent, quantity, dosage regimen/duration), and answer whether other prescribers involved in the concurrent therapy are aware and have been consulted. Ensure the prescriber attestation is signed (wet signature required; electronic or stamped signatures are not accepted).

PA is required when a new opioid will be used concurrently with benzodiazepines and exceeds seven days within a 180-day period.
PA is required when a new benzodiazepine will be used concurrently with opioids and exceeds seven days within a 180-day period and/or exceeds established benzodiazepine/opioid concurrent therapy quantity limits (see Sedative Hypnotics Benzodiazepine PA criteria).
Form must include: Patient's Medicaid #, patient name, DOB, dates of service (mark if retroactive), prescriber's name, IN license #, specialty, NPI, prescriber signature (required), return fax/phone.
List requested opioid agent(s) with prescriber name, quantity, and dosage regimen/duration. If multiple prescribers, indicate whether other prescribers are aware and have been consulted.
Include attestation confirming review of the member's INSPECT report (do not attach the report), counseling the member on risks of concurrent therapy, consultation with other prescribers if applicable, and acknowledgement of risks (respiratory depression, coma, death).

Key Definitions

Concurrent benzodiazepine and opioid therapy — threshold

Concurrent therapy thresholdConcurrent benzodiazepine and opioid therapy exceeding seven days within a 180-day period

When PA is requiredClaim(s) for new opioid(s) to be used concurrently with benzodiazepines and exceeding seven days within a 180-day period; claim(s) for new benzodiazepine(s) to be used concurrently with opioids and exceeding seven days within a 180-day period

Additional limitsConcurrent benzodiazepine/opioid therapy quantity limits may also trigger PA (see Sedative Hypnotics Benzodiazepine PA criteria)

INSPECT (state prescription monitoring program) report

INSPECT report reviewPrescriber must evaluate the member's INSPECT report and continue to evaluate it on a regular basis; do NOT attach a copy of the INSPECT report to the PA request (per IC 35-48-7-11.1)

Attestation requirementPrescriber must attest that the INSPECT report has been evaluated as part of the PA attestation section

Prescriber signaturePrescriber signature is required for consideration; electronic or stamped signatures are not accepted

OpenPayer

Request for Prior Authorization - Benzodiazepine and Opioid Concurrent Therapy

Prior Authorization Coverage Criteria

Coding and Thresholds

Provider Submission Requirements

Key Definitions