CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization form and coverage criteria — Antidepressants (serotonin modulators)

A payer-specific prior authorization request form and criteria checklist for antidepressant medications (serotonin modulators) used for Washington members; governs documentation and trial requirements for new or continuing therapy requests submitted to Colorado Rocky Mountain Health Plans via the provided fax and phone contacts.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization form and coverage criteria — Antidepressants (serotonin modulators)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form by fax to 866-940-7328 and include chart notes documenting three failed preferred antidepressant trials from at least two subclasses.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

866-940-7328fax number to submit form

800-310-6826phone number for questions

24 hoursallow at least this long for review

3required failed preferred trials

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Coverage Criteria

Authorization criteria

Covered when ALL of the following are met

Form completion: Completed prior authorization form submitted to payer with required fields (member info, provider info, medication, strength, directions, quantity, ICD-10 code)

Fax to 866-940-7328; allow at least 24 hours for review

Documentation: Chart notes attached and prescriber signature/specialty included

Missing chart notes or signature may delay/deny

Prior medication trials: Patient has tried and failed three preferred antidepressants from at least two antidepressant subclasses listed (per question 4)3 failed trials, >=2 subclasses

List medications, dates, and reasons for failure in Section D

Continuation therapy: If continuation, document start date and documented positive clinical response

Indicate continuation and positive response in Section A and Question 1

Preferred alternatives should be used when appropriate. The form directs providers to the payer's preferred drug list for alternatives and asks for an explanation if a preferred medication would not meet the patient's needs. Document the clinical rationale in Section E and reference the PDL at www.uhcprovider.com when explaining why a preferred agent is not suitable.

Requests that do not include documentation of prior preferred medication trials or a clinical justification for use of a non-preferred antidepressant may be considered unsupported. Use Section D to list prior medications, dates of therapy, and reason for failure or discontinuation; omission of this information can render the request incomplete.

Coding

Requested diagnosis code fieldICD-10

ICD-10 CODE

Place to enter the patient's diagnosis ICD-10 code as requested on the form

Number of failed preferred antidepressant trials

Required number of failed preferred antidepressant trials3

Required diversity of subclasses for failed trialsFailures must include agents from at least 2 different antidepressant subclasses

Where to record trials on formList trials in Section D – Previous Medication Trials (medication name, strength, directions, dates, reason for failure)

Provider Actions & Submission Requirements

Prior Authorization

Prior authorization submission and clinical trial documentation

Prior Authorization Request Form: Please complete this entire form and fax it to 866-940-7328. If you have questions, call 800-310-6826. Complete all pages to avoid delay; allow at least 24 hours for review.

Use the Prior Authorization Request Form and include all pages
Fax completed form to 866-940-7328 or call 800-310-6826 for questions

Step Therapy

Required prior trials

Patient must have tried and failed three preferred antidepressants from at least two antidepressant subclasses listed (e.g., SSRI, SNRI, Tricyclics, MAOI, NDRI, Alpha-2 receptor antagonists). Document each trial with medication name, strength, directions, dates of therapy, and reason for failure/discontinuation.

List at least three prior antidepressant trials
Trials must include medications from at least two different subclasses

Background

This form is used to collect the clinical information necessary for prior authorization of serotonin modulator antidepressants. It captures whether the request is for continuation of therapy, documents prior medication trials and failures, and requests confirmation of a documented clinical response when applicable to support approval decisions.

Definitions

Failure of preferred antidepressant — definition/indicator

Definition of failureFailure includes trial and discontinuation of a preferred antidepressant documented in Section D with reason for failure/intolerance or lack of efficacy

Documentation requiredRecord medication name, strength, directions, dates of therapy, and reason for failure/discontinuation in Section D

Subclass requirementFailed preferred agents must come from at least two different Apple Health antidepressant subclasses (see question 4 checkboxes)

Reference for preferred alternativesRefer to the payer's preferred drug list (PDL) for preferred alternatives at www.uhcprovider.com

Initial Therapy Criteria

Initial therapy requirements

Initial therapy requests must document prior medication trials and failures.

Prior trials: Document trials of preferred antidepressants (medication name, strength, directions, dates of therapy, and reason for discontinuation); must have failed three preferred agents from at least two antidepressant subclasses3 failed trials, >=2 subclasses

Use Section D to list each medication, dates, and reason for failure; see Apple Health PDL for preferred alternatives

Continuation Therapy Criteria

Continuation therapy requirements

Continuation of therapy requests must document start date and clinical response.

Continuation documented: If continuation of therapy, provide therapy start date and indicate whether the patient has a documented positive clinical response

Document continuation status in Section A and clinical response in Question 1; include supporting chart notes and prescriber signature

Step Therapy Requirements

Requirement	Details / Documentation
Step therapy requirement
Patient must have tried and failed three preferred antidepressants from at least two different antidepressant subclasses listed on the payer's preferred drug list (PDL)
Required subclasses (select at least two)
Alpha-2 Receptor Antagonists (Tetracyclics); Monoamine Oxidase Inhibitors (MAOI); Norepinephrine-Dopamine Reuptake Inhibitors; Selective Serotonin Reuptake Inhibitors (SSRI); Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRI); Tricyclic Agents
Documentation to submit
List of all antidepressants tried (Section D) with strength, directions, dates of therapy, and reason for failure/discontinuation; chart notes attached; if continuation, indicate start date and documented positive clinical response (Section A/clinical questions)
Where to reference preferred alternatives
Refer to the patient's PDL at www.uhcprovider.com for the list of preferred alternatives (per Section D/E)
Submission instructions
Submit completed prior authorization form with required documentation by fax to 866-940-7328 (questions: 800-310-6826); incomplete requests (missing chart notes, prescriber signature, or specialty) may be delayed or denied