CurrentColorado Rocky Mountain Health PlansPolicy N/A

Sedative-hypnotic / Non-preferred drug prior authorization and quantity limit form

Provider/prescriber form to request non-preferred sedative-hypnotic drugs or to request exceeding a quantity limit (>15 per 30 days). Captures beneficiary, prescriber, drug, rationale for non-preferred use, and checklist criteria for quantity limit exceptions/tapering/assessment for chronic insomnia.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySedative-hypnotic / Non-preferred drug prior authorization and quantity limit form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and sign the beneficiary/prescriber form documenting patient identifiers, drug name/strength/quantity, length of therapy (max 180 days), and at least one justification from the listed reasons for non-preferred use.

POLICY UPDATE CHANGES

No material clinical/coverage changes

15/30dStandard Quantity Limit

180dMax Length of Therapy

2Preferred Drug Failures Required

3wNon-pharmacologic Trial Minimum

Policy summary & scope

This is a provider/prescriber form to request either a non-preferred sedative-hypnotic agent or an exception to the standard quantity limit of 15 per 30 days. The form captures beneficiary identifiers (name, ID, DOB, gender), prescriber identifiers (including NPI and contact), and detailed drug information (name, strength, quantity per 30 days, and length of therapy — maximum 180 days). For non-preferred drug requests, the form requires documentation of rationale such as failure of preferred therapies, adverse reactions, contraindications, age-specific indications, literature/FDA support, or unacceptable risk with therapeutic change. For quantity-limit exceptions (>15 per 30 days), the form includes checklist items covering a diagnosis of chronic primary insomnia (lasting one month or longer), documentation of a >= 3 week trial of non-pharmacologic therapies/good sleep hygiene, assessment/treatment of comorbid causes if secondary insomnia, tapering rationale if discontinuing a sedative-hypnotic, and active assessment for insomnia.

Approval and quantity-exception criteria

Non-Preferred Drug Approval Conditions

Request must document one or more of the following reasons for use of a non-preferred drug:

ANY of the following

Failed two preferred drug(s); list preferred drugs failed and document reasons (including allergic reactions or drug-drug interactions).
Include listing of preferred drugs failed and documentation of reasons (e.g., allergic reactions, drug-drug interactions).
Previous episode of an unacceptable side effect or therapeutic failure to preferred drugs; provide clinical information.
Provide clinical information describing the side effect or therapeutic failure.
Clinical contraindication, co-morbidity, or unique patient circumstance that contraindicates preferred drug(s); provide clinical information.
Provide clinical information describing the contraindication or comorbidity.
Age specific indications: provide patient age and explanation.
Provide patient age and explanation for age-specific indication.
Unique clinical indication supported by FDA approval or peer-reviewed literature; explain and provide reference.
Explain indication and provide FDA approval or peer-reviewed literature reference.
Unacceptable clinical risk associated with therapeutic change; explain.
Explain the unacceptable clinical risk associated with changing therapy.

Quantity Limit (>15 per 30 days) Exception Criteria

Exceeding a quantity of 15 per 30 days is allowed when ALL applicable criteria are met as documented:

ALL of the following

Diagnosis of chronic primary insomnia lasting one month or longer.
Checkbox Yes/No on form
Beneficiary has received information on good sleep hygiene and had a documented trial (at least 3 weeks) of non-pharmacological therapies (e.g., stimulus control, sleep restriction, sleep hygiene measures, relaxation therapy).minimum 3 weeks
Checkbox Yes/No on form; minimum 3 weeks
If chronic secondary or co-morbid insomnia
- Underlying psychiatric illness associated with insomnia and is being evaluated/treated.

Required documentation & submission steps

Prior Authorization

Submit non-preferred drug request

Complete and sign the beneficiary/prescriber form. Include patient identifiers, drug name, strength, quantity per 30 days, and select length of therapy (max 180 days). Provide at least one justification from the listed reasons for non-preferred use (e.g., failed preferred drugs, adverse reaction, clinical contraindication, age-specific indication, literature/FDA-supported indication, or unacceptable risk from therapeutic change).

Include beneficiary name, ID, date of birth and prescriber NPI/contact.
Record drug name, strength, quantity per 30 days, and check length of therapy (up to 180 days).
Provide at least one justification from the non-preferred drug checklist.

Documentation Required

Document failed preferred therapies

Document either failure of two preferred drugs (listing the specific agents and reasons such as allergic reactions or drug–drug interactions) or provide other applicable clinical information: prior unacceptable side effect or therapeutic failure, clinical contraindication/co-morbidity or unique circumstance, age-specific indication with age noted, or a unique indication supported by FDA approval or peer‑reviewed literature.

List the two preferred drugs that failed and describe the reason(s) for failure.
If not failed therapies, provide clinical contraindication, adverse reaction details, age-specific rationale, or literature/FDA support.

Documentation Required

Document quantity-limit exception criteria

When requesting more than 15 per 30 days, document that all applicable exception criteria are met: diagnosis of chronic primary insomnia lasting one month or longer; documented trial (at least 3 weeks) of non‑pharmacologic therapies and education on sleep hygiene; if secondary/co‑morbid insomnia, documentation that the underlying psychiatric, medical, or sleep disorder is being evaluated/treated; if discontinuing a sedative hypnotic, provide tapering rationale to prevent withdrawal; or document active assessment for chronic insomnia where applicable.

Confirm chronic primary insomnia diagnosis and duration (≥1 month) when applicable.
Document non‑pharmacologic therapy trial of at least 3 weeks (e.g., stimulus control, sleep restriction, relaxation).
If secondary insomnia, document evaluation/treatment of psychiatric, medical, or sleep disorder cause.
If discontinuing a sedative hypnotic, document need for tapering to prevent withdrawal.
Or document active assessment for chronic primary or secondary insomnia (if not already diagnosed).

Documentation Required

Prescriber signature required

Prescriber signature on the form is mandatory. The prescriber must sign and date to certify the information is accurate and complete; unsigned requests may be considered non‑compliant and can be denied.

Signature certifies accuracy and completeness and is required for processing.
Unsigned requests may be denied.

Form purpose & context

This Colorado Rocky Mountain Health Plans form is used to collect the clinical information necessary to justify use of non-preferred sedative-hypnotic agents and to request exceptions to the standard quantity limit. It documents beneficiary and prescriber identifiers, specific drug details (name, strength, quantity per 30 days, and length of therapy up to 180 days), and requires selection of one or more justifications for non-preferred use (for example, failed two preferred drugs, prior unacceptable side effects, clinical contraindication, age-specific indication, literature/FDA support, or unacceptable risk with change). For requests to exceed 15 per 30 days, the form captures checklist items including chronic insomnia duration (one month or longer), a documented trial of non-pharmacologic therapies of at least 3 weeks, documentation of evaluation/treatment for comorbid conditions when applicable, tapering requirement if discontinuing a sedative-hypnotic, and prescriber signature certifying accuracy.

OpenPayer

Sedative-hypnotic / Non-preferred drug prior authorization and quantity limit form

Policy summary & scope

Approval and quantity-exception criteria

Required documentation & submission steps

Codes referenced on form

Key terms

Form purpose & context