CurrentColorado Rocky Mountain Health PlansPolicy N/A

Antidepressants (Washington) Prior Authorization Form - Community Planopen_in_new

Prior authorization request form and criteria checklist used by Colorado Rocky Mountain Health Plans / Community Plan (Washington) for non-preferred antidepressant medications, documenting patient, provider, clinical history, prior medication trials, concomitant psychotropic use, and continuation criteria to support PA decisions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAntidepressants (Washington) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete entire prior authorization form, including Sections A–E, and fax to 866-940-7328; allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported for this update.

Form-based PAAuthorization Mechanism

Multi-classAntidepressant Classes Addressed

Concomitant trackingPsychotropic Concomitant Use Options

Coverage Summary & Scope

This prior authorization form is used to collect clinical and administrative information to evaluate requests for non-preferred antidepressant medications for Washington Community Plan members. It captures member and provider identification, medication details (name, strength, directions, quantity), specific diagnosis with ICD-10 code, pregnancy status, hospitalization/discharge dates, prior medication trials with reasons for failure or discontinuation, concomitant psychotropic medication status, and documentation of positive response for continuation requests. Providers must complete Sections A–E and fax the form to 866-940-7328 and allow at least 24 hours for review.

Key Contextual Items

Authorization MechanismForm-based prior authorization; providers must complete Sections A–E and fax to 866-940-7328 (allow ≥24 hours for review)

Antidepressant Classes AddressedMulti-class: SSRI, SNRI, NDRI (bupropion), TeCA (Alpha-2 receptor antagonists/tetracyclics), Serotonin Modulator–Miscellaneous (SMM)

Psychotropic Concomitant Use OptionsDocument whether patient will remain on both meds, transitioning, will remain on ≥5 psychotropic meds, or transitioning to <5 (list meds and stop dates); class-specific concomitant-use questions require Section D completion

Prior Authorization Criteria (All Requests)

All Requests

Request will be considered when ALL of the following are documented:

ALL of the following

Required sections/info
- Member and provider information: Completed member information and provider information sections (Sections A and B)
- Medication details: Medication: name, strength, directions, quantity, and specific diagnosis with ICD-10 code
- New vs continuation: Indication whether request is new or continuation of therapy; if continuation, list start date
- Hospitalization status: If currently hospitalized or discharged on requested non-preferred behavioral health medication, provide start date and discharge date
- Pregnancy status: If patient is pregnant, provide pregnancy status and due date
- Previous medication trials section: Documentation of previous medication trials (Section D) including medication name, strength, directions, dates of therapy, and reason for failure/discontinuation

History of failure/contraindication/intolerance

TeCA: Alpha-2 Receptor Antagonists (Tetracyclics)
NDRI: Norepinephrine-Dopamine Reuptake Inhibitors (NDRI)
SSRI: Selective Serotonin Reuptake Inhibitors (SSRI)
SNRI: Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
SMM: Serotonin Modulators/Miscellaneous (SMM)

Trial-of-preferred-products

Preferred product trials: Trial of two preferred products, other than the generic equivalent to the requested brand
Generic manufacturer trials: Trial of the generic equivalent of the product being requested from 5 manufacturers (or all manufacturers if fewer than 5)

Concomitant psychotropic medication status (must document applicable option)

Remain on both: Patient will remain on both medications (transitioning and remaining on both) — list medications used together
Transitioning stop: Transitioning from one antidepressant to another — list medication that will be stopped and date
Remain on five or more: Patient will remain on five or more psychotropic/mental health medications
Transitioning less than five: Transitioning medications AND will be on LESS THAN five psychotropic medications — list drugs to be stopped and date

Class-specific concomitant-use note: For class-specific concomitant-use questions, documentation of concomitant use must be provided and Section D completed if applicable (SSRI, TeCA, NDRI, SMM, SNRI)

Continuation of therapy requirement: For continuation of therapy requests: documentation of positive clinical response to treatment (Section: Continuation of Therapy)

What Providers Must Do

Prior Authorization

Submit completed PA form

Complete Sections A–E of the prior authorization form and fax the entire form to 866-940-7328. Allow at least 24 hours for review after submission.

Documentation Required

Document prior medication trials

Provide prior medication trials including medication name, strength, directions, dates of therapy, and reason(s) for failure or discontinuation. Document trials of two preferred products (not the generic equivalent of the requested brand) and trials of the generic equivalent of the requested product from five manufacturers (or all manufacturers if fewer than five).

Medication name, strength, directions, dates of therapy
Reason for failure or discontinuation
Trial of two preferred products (other than the generic equivalent to the requested brand)
Trial of the generic equivalent from 5 manufacturers (or all manufacturers if fewer than 5)

Documentation Required

Document concomitant medication status

Indicate whether the patient will remain on both medications or is transitioning from one antidepressant to another; if transitioning, list the medication to be stopped and the stop date. List all concurrent psychotropic/mental health medications and, when applicable, specify planned discontinuations with dates. For class-specific concomitant-use questions, complete Section D if applicable.

State if patient will remain on both medications and list medications used together
If transitioning, list medication to be stopped and the date it will be stopped
List concurrent psychotropic medications and planned discontinuations with dates
Complete Section D when concomitant-use questions apply

Documentation Required

Continuation of therapy evidence

For continuation of therapy requests, include documentation of a positive clinical response to treatment and provide details of the response in the continuation section of the form.

Document positive clinical response
Describe response details (listed in the continuation section)

OpenPayer

Antidepressants (Washington) Prior Authorization Form - Community Planopen_in_new

Coverage Summary & Scope

Prior Authorization Criteria (All Requests)

What Providers Must Do

Codes

Definitions

Revision History