CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Ambien Prior Authorization Request Form

A prior authorization request form for selected hypnotic/sedative medications requiring provider-completed clinical information about diagnosis, dosing conformity, prior trials/failures or contraindications to formulary alternatives, and documentation to support coverage decisions. It specifies required fields and documentation to avoid denial.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina (OptumRx)

PolicyAmbien Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and submit the prior authorization form with all required clinical fields and supporting documentation; form may be faxed to 844-403-1029 or submitted via go.covermymeds.com/OptumRx.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage criteria or policy content.

6Medications listed on form

1Required signature

2+Preferred alternatives to trial for majority

Coverage Summary

Scope: Prior authorization for selected hypnotic and sedative medications (Ambien, Ambien CR, Belsomra, Edluar, Intermezzo, Silenor). The form requires provider-completed clinical information about diagnosis, dosing conformity, prior trials/failures or contraindications to formulary alternatives, and supporting documentation to inform coverage decisions.

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Authorization criteria (form requirements)

Authorization criteria

Form requires documentation that ALL of the following are provided and met for consideration:

ALL of the following

Provider/Member identification: Provider completes required member and provider identification fields (Member Name, Provider Name, Insurance ID#, NPI#, Specialty, DOB, contact information).
Form may be faxed to 844-403-1029 or submitted via CoverMyMeds/OptumRx portal (go.covermymeds.com/OptumRx).
Medication information provided (Medication Name, Strength, Dosage Form, Directions for Use).
Diagnosis and ICD-10: Diagnosis selected and ICD-10 code provided (primary example: Insomnia; other diagnosis allowed with ICD-10 code).
Dose conformity
- Dose conformity branch
  - Dose within guidelines: Yes — dose within manufacturer's or compendia guidelines.
  - Dose outside guidelines: No — dose outside guidelines (requires explanation/documentation).
Prior agent status
- Prior trials branch
  - Prior trials - yes: Yes — submit documentation of trials, dates, reasons for failure/intolerance.
  - Prior trials - no: No — leave blank or indicate none (may lead to denial).
Contraindication to formulary alternatives
- Contraindication branch
  - Contraindication - yes: Yes — provide documentation.
  - Contraindication - no: No — indicate none.
Adverse reaction to formulary agents
- Adverse reaction branch
  - Adverse reaction - yes: Yes — provide documentation.
  - Adverse reaction - no: No — indicate none.
No listed formulary alternative
- No formulary alternative branch
  - No alternative - yes: Yes — submit clinical documentation.
  - No alternative - no: No — indicate none.
Prescriber signature: Prescriber's signature and date certifying accuracy of information.
Information on form is accurate as of this date.

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Required provider actions

Prior Authorization

Submit completed PA form

Complete and submit the OptumRx prior authorization form with all required clinical fields and supporting documentation. The form may be faxed to 844-403-1029 or submitted online via the CoverMyMeds portal at go.covermymeds.com/OptumRx.

Documentation Required

Document prior trials, contraindications, adverse reactions

Provide documentation of prior medication trials, contraindications, and adverse reactions. Include medication names, dates of the trial(s), and the specific reason each treatment failed or was not tolerated (or indicate none if not applicable).

List medication(s) tried
Provide dates of each trial
State reason for treatment failure or intolerance

Denial Risk

Incomplete requests may be denied

Requests may be denied unless all required information and supporting documentation are provided. Ensure every required field on the form is completed and any requested clinical documentation is attached to avoid denial.

Billing Rule

Submission channels

Prior authorization requests can be submitted using the CoverMyMeds portal (go.covermymeds.com/OptumRx) for potential real-time determinations or faxed to 844-403-1029. Use either channel to transmit the completed form and supporting documentation.

Background

Background: This prior authorization request form is used by OptumRx/Blue Cross Blue Shield - South Carolina to collect required clinical information for coverage review of selected hypnotic/sedative agents. Providers may submit requests via CoverMyMeds (go.covermymeds.com/OptumRx) for potential real-time determinations or fax the form to 844-403-1029.

The form requires completion of member and provider identification fields and medication information (Member Name, Provider Name, Insurance ID#, NPI#, Specialty, DOB, contact information; and Medication Name, Strength, Dosage Form, Directions for Use).

Dosing: The form asks whether the prescribed dose is within the manufacturer’s published dosing guidelines or within dosing guidelines found in accepted compendia or current literature (e.g., package insert, AHFS, Micromedex, current accepted guidelines) and requires documentation/explanation if the dose falls outside those guidelines.

Required documentation: The form requires documentation of failure/intolerance to a majority of preferred formulary alternatives (medication(s) tried, dates of trial(s), and reason for treatment failure(s)), or documentation of documented contraindications or adverse reactions to listed formulary alternatives, or documentation that no listed formulary agent exists for the clinical condition. The form notes that the request may be denied unless all required information is received.

Definitions: Majority of preferred formulary alternatives — Defined in the form as two or more agents in a class with at least two alternatives, or one in a class with only one alternative.