Prior Authorization for Sedative-Hypnotic Sleep Medications
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MassHealth requires written prior authorization for all medications FDA-approved primarily to treat insomnia for MassHealth patients; this bulletin instructs participating prescribers, pharmacists, and providers on the prior authorization process and limits.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior authorization criteria for insomnia medications
Covered when ALL of the following are met
Any listed drug or new-to-market insomnia drug counts toward yearly limit
Benzodiazepines that are FDA-approved for a primary purpose other than the treatment of insomnia (for example, diazepam, lorazepam, or alprazolam) are not subject to the prior authorization requirements
Coding and Prescribing Guidance
| No codes listed |
Provider Actions and Requirements
Prior authorization required for insomnia drugs
All medications that are FDA‑approved for the primary treatment of insomnia require written prior authorization effective April 1, 2000. The initial prescription request in a 12‑month period for up to a 30‑day supply may be made by the pharmacist by calling the Drug Utilization Review Program; all subsequent requests must be made in writing by the prescriber. Prior authorization, if granted, will be for a maximum 30 days and the Division allows a maximum of three 30‑day prior authorizations in any consecutive 12‑month period.
- Effective date: April 1, 2000
- Initial pharmacist-initiated 30‑day request allowed by phone to the Drug Utilization Review Program
- Subsequent requests must be submitted in writing by the prescriber
- Each approved prior authorization covers a maximum 30‑day supply
- Maximum of three 30‑day prior authorizations per any consecutive 12‑month period
Provider contact and support
Prescribers must follow the submission routing and contact instructions provided in the bulletin for prior authorization questions or assistance.
- Contact Unisys Provider Services Department at (617) 628-4141 or 1-800-325-5231 for questions
Required prior authorization documentation
The prescriber must complete a Request for Prior Authorization form or submit a written request on office letterhead containing the information required in Subchapter 5 of the provider manual and must include the pharmacy name, address, and telephone number. Send or fax the completed form or request to the Drug Utilization Review Program at the address or fax listed in the bulletin.
- Mail to: Drug Utilization Review Program, University of Massachusetts Medical School, 11 Midstate Drive, Auburn, MA 01501
- Fax: (508) 721-7138
- Phone (for questions only): (800) 745-7318
Denial risk for excess authorizations or longer durations
Prior authorizations may be denied if requests exceed program limits or request durations beyond the allowed approvals. Specifically, requests that exceed three 30‑day prior authorizations in any consecutive 12‑month period or request durations longer than the 30‑day maximum are subject to denial.
- Maximum of three 30‑day prior authorizations per any consecutive 12‑month period — exceeding this may result in denial
- Each authorization is granted for a maximum 30 days — requests for longer durations may be denied
Background
Insomnia is a common sleep disorder; while many patients can be managed without medication, sedative-hypnotic drugs are sometimes indicated. Clinical evidence summarized in the bulletin notes that many sleep medications lose effectiveness after several weeks, so use should generally be limited to 2–3 weeks. For MassHealth coverage, all medications FDA‑approved for the primary treatment of insomnia require written prior authorization beginning April 1, 2000, with an initial pharmacist-initiated phone request allowed for a single 30‑day supply in any 12‑month period; subsequent supplies require a prescriber’s written prior authorization.
Definitions
Initial Therapy Criteria
Initial dispensing rule
Initial dispensing within a 12-month period
Prescriber must later submit written PA for further supplies
Step Therapy and Duration Limits
| Policy element | Rule / limit |
|---|---|
| Recommended usual duration of therapy (clinical guidance) | |
| Limit use to 2–3 weeks when clinically appropriate; many agents lose effectiveness after several weeks of continued use. | |
| Prior authorization maximum duration per approval | |
| If prior authorization is granted, it will be for a maximum 30-day supply. | |
| Number of prior authorizations allowed in any consecutive 12-month period | |
| A maximum of three 30-day prior authorizations are allowed in any consecutive 12-month period. | |
| Initial dispensing exception | |
| Initial pharmacist-initiated request in a 12-month period may be made by phone for up to a 30-day supply; subsequent requests must be submitted in writing by the prescriber. |
Quantity Limits
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