CurrentNeighborhood Health Plan of Rhode IslandPolicy 382-D

Non-benzodiazepine hypnotics (branded) step therapy

Defines step therapy and prior authorization criteria for coverage of branded non-benzodiazepine hypnotic drugs for members under the payer's prescription benefit. Affects providers submitting claims and PA requests for these branded insomnia agents.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-benzodiazepine hypnotics (branded) step therapy

Policy CodePolicy 382-D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvide documentation of a 30-day generic non‑benzodiazepine hypnotic fill within the past 730 days or documentation of contraindication/intolerance when submitting a PA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysrequired prior trial duration

730 dayslookback period

24 monthsduration of approval

1number of generics required

Coverage Criteria

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Authorization criteria: Patient has experienced an inadequate treatment response after at least a 30 day trial of at least ONE generic non-benzodiazepine hypnotic drug.trial >= 30 days of >=1 generic non-benzodiazepine hypnotic

Supports coverage when trial documented

Authorization criteria: Patient has a documented contraindication or a potential drug interaction that would prohibit a trial of at least ONE generic non-benzodiazepine hypnotic drug.documented contraindication or interaction

Allows bypass of trial requirement

Authorization criteria: Patient has experienced an intolerance to at least ONE generic non-benzodiazepine hypnotic drug.documented intolerance to >=1 generic non-benzodiazepine hypnotic

Allows bypass of trial requirement

Initial Step Therapy

Member must meet the step therapy requirement below to have the requested branded drug paid under the prescription benefit; otherwise the claim will reject and PA criteria apply.

Initial step therapy: Member must have filled a prescription for at least a 30 day supply of at least one generic nonbenzodiazepine hypnotic within the past 730 days under the prescription benefit administered by CVS Caremark.30 days within 730 days

If met, branded drug will be paid under the prescription benefit; if not met, claim rejects and PA criteria apply.

Step	Requirement	Lookback period	Exemptions / Alternative criteria
1	Trial of at least one generic non-benzodiazepine hypnotic for ≥30 days	Within the past 730 days	Documented contraindication, potential drug interaction, or intolerance to at least one generic non-benzodiazepine hypnotic

Coding & Timeframes

inv-02: Required prior trial duration

Required prior trial duration>= 30 days

Minimum number of generic agentsAt least 1 generic non‑benzodiazepine hypnotic

PurposeEstablish inadequate response, contraindication, or intolerance before branded coverage

inv-03: Lookback period for prior fill

Lookback period for prior fill<= 730 days

ApplicationMust have been filled under the prescription benefit administered by CVS Caremark within this period

Consequence if not metClaim will reject and prior authorization is required

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required if Step Not Met

Prior authorization is required when the member has not met the Initial Step Therapy requirement (no evidence of a 30‑day fill of a generic non‑benzodiazepine hypnotic within the past 730 days). Requests for the branded agent will be evaluated under the PA criteria when the step is not met.

Applies when no 30‑day generic non‑benzodiazepine hypnotic fill is found in past 730 days
PA unit will evaluate submitted prior authorization requests

Denial Risk

Initial Step Therapy Rejection

If the patient has not filled at least a 30‑day supply of at least one generic non‑benzodiazepine hypnotic within the past 730 days, the claim will reject with a message indicating that prior authorization is required. The provider must submit a PA request for the branded drug; adjudication will follow the PA criteria.

Rejection message will indicate PA is required
Submit PA to override step-therapy rejection

Documentation Required

Required Supporting Documentation

Documentation must be provided to support that the member met the initial step therapy requirement or to justify medical necessity for bypassing the step. Acceptable documentation includes evidence of a filled prescription for at least a 30‑day supply of a generic non‑benzodiazepine hypnotic within the past 730 days, or clinical documentation supporting contraindication, intolerance, or inadequate response to such agents.

Prescription fill history showing at least a 30‑day supply within past 730 days
Clinical documentation of contraindication to all generic non‑benzodiazepine hypnotics
Clinical documentation of intolerance or inadequate response to at least one generic non‑benzodiazepine hypnotic

Step Therapy

Initial Step Therapy Requirement

Initial Step Therapy: Authorization for the requested branded agent will be granted when ONE of the following is met: (1) patient has experienced an inadequate treatment response after at least a 30‑day trial of at least one generic non‑benzodiazepine hypnotic; (2) patient has a documented contraindication or potential drug interaction prohibiting trial of at least one generic non‑benzodiazepine hypnotic; or (3) patient has experienced an intolerance to at least one generic non‑benzodiazepine hypnotic. If the patient meets the step (a ≥30‑day fill within the past 730 days), the branded drug will be paid without PA under the prescription benefit.

Authorization when ONE of: inadequate response after ≥30‑day trial; documented contraindication/interaction; documented intolerance
If step met (≥30‑day generic fill within 730 days), branded drug paid under benefit without PA

Definitions

inv-09: Generic non‑benzodiazepine hypnotic trial

DefinitionA trial consisting of at least a 30‑day supply of at least one generic non‑benzodiazepine hypnotic medication.

Minimum supply length30 days

Agent requirementAt least one generic non‑benzodiazepine hypnotic

Role in policyMeets initial step therapy requirement to allow coverage of branded agents when documented

Background

Insomnia agents include both branded and generic non‑benzodiazepine hypnotics. Under this policy, coverage of branded non‑benzodiazepine hypnotics is subject to an initial step therapy requirement: the member must have tried at least one generic non‑benzodiazepine hypnotic prior to coverage of a branded agent unless an exception applies. Specifically, authorization may be granted when one of the following is documented: 1) an inadequate treatment response after at least a 30‑day trial of at least one generic non‑benzodiazepine hypnotic; 2) a documented contraindication or potential drug interaction that would prohibit a trial of at least one generic non‑benzodiazepine hypnotic; or 3) intolerance to at least one generic non‑benzodiazepine hypnotic.

If the member has filled a prescription for at least a 30‑day supply of a generic non‑benzodiazepine hypnotic within the prior 730 days under the prescription benefit administered by CVS Caremark, the requested branded drug will be paid under the prescription benefit. If that initial step is not met, the claim will reject and a prior authorization is required; PA review will apply the coverage criteria above.