CurrentNeighborhood Health Plan of Rhode IslandPolicy 382-D

Insomnia agents (branded nonbenzodiazepine hypnotics) — Coverage and prior authorization

Coverage and prior authorization requirements for branded insomnia/hypnotic drugs for members of Neighborhood Health Plan of Rhode Island; governs pharmacy benefit coverage and step therapy for these agents.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInsomnia agents (branded nonbenzodiazepine hypnotics) — Coverage and prior authorization

Policy CodePolicy 382-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization if the patient has not filled a ≥30-day supply of a generic non‑benzodiazepine hypnotic within the past 730 days; include documentation of inadequate response, contraindication/interaction, or intolerance if applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 monthsDuration of approval

730 daysLookback period

30 daysRequired trial

4+Branded products

Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInsomnia agents (branded nonbenzodiazepine hypnotics) — Coverage and prior authorization

Policy CodePolicy 382-D

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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Criteria options: (1) The patient has experienced an inadequate treatment response after at least a 30 day trial of at least ONE generic non-benzodiazepine hypnotic drug; (2) The patient has a documented contraindication or a potential drug interaction that would prohibit a trial of at least ONE generic non-benzodiazepine hypnotic drug; (3) The patient has experienced an intolerance to at least ONE generic non-benzodiazepine hypnotic drug.see node text

These are alternative (OR) criteria; meeting any one allows authorization.

This section describes the coverage criteria that determine when authorization for branded non‑benzodiazepine hypnotic agents may be granted. Authorization may be approved when the member meets one of the alternative clinical criteria: an inadequate treatment response following a ≥30‑day trial of at least one generic non‑benzodiazepine hypnotic, a documented contraindication or potential drug interaction that prevents trial of a generic agent, or a documented intolerance to at least one generic non‑benzodiazepine hypnotic. These criteria are applied when the initial step therapy requirements are not met under the prescription benefit.

Under the CVS Caremark‑administered prescription benefit the initial step therapy requirement is that the member must have filled a ≥30‑day supply of at least one generic non‑benzodiazepine hypnotic within the prior 730 days; if that condition is met the branded drug will be paid without prior authorization. If the member does not meet the step therapy condition, the claim will reject and a prior authorization request must be submitted and evaluated against the authorization criteria above.

Coding & Key Parameters

Step therapy lookback

Lookback period for step therapy>= 730 days (member must have filled a qualifying generic within the past 730 days)

Benefit administrationApplies to prescriptions filled under the CVS Caremark-administered prescription benefit

Consequence if not metClaim will reject and require prior authorization if no qualifying fill in prior 730 days

Required generic trial duration

Required trial duration of generic agent>= 30 days (patient must have had at least a 30‑day supply of a generic non‑benzodiazepine hypnotic)

Where duration appliesTrial must be within the prior 730 days under the CVS Caremark benefit to meet initial step therapy

Authorization alternativeIf the 30‑day trial is not met, PA criteria (inadequate response, contraindication/interaction, or intolerance) may allow authorization

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required when the initial step therapy requirement is not met. Authorization may be granted if the patient meets one of the coverage criteria below.

If the member has not met the Initial Step Therapy requirement (see step-therapy callout), the claim will reject and require prior authorization.
PA requests are evaluated by the prior authorization unit.

Step Therapy

Initial Step Therapy

Initial step therapy: member must have filled a ≥30-day supply of at least one generic non-benzodiazepine hypnotic within the prior 730 days under the prescription benefit administered by CVS Caremark. If this requirement is met, the requested branded drug will be paid under that prescription benefit; if not met, claims will reject and require prior authorization.

Filled ≥30-day supply of at least one generic non-benzodiazepine hypnotic within the prior 730 days (CVS Caremark-administered prescription benefit).

Documentation Required

Required Clinical Documentation

Documentation must show one of the following to support approval when step therapy is not met: inadequate response, contraindication/potential drug interaction, or intolerance to at least one generic non-benzodiazepine hypnotic.

Inadequate treatment response after at least a 30-day trial of at least one generic non-benzodiazepine hypnotic drug.
Documented contraindication or potential drug interaction that would prohibit a trial of at least one generic non-benzodiazepine hypnotic drug.
Documented intolerance to at least one generic non-benzodiazepine hypnotic drug.

Initial Therapy Criteria

Initial Step Therapy

Covered when ALL of the following are met:

Initial step therapy: Patient must have filled at least a 30 day supply of at least one generic non-benzodiazepine hypnotic within the past 730 days under the CVS Caremark-administered prescription benefit to have the requested branded drug paid under that benefit without prior authorization.>= 30 days; lookback >= 730 days

If this requirement is not met the claim will reject and prior authorization criteria apply.

Step Therapy Details

Requirement	Details
Step	1
Requirement	Member must have filled a ≥30‑day supply of at least one generic non‑benzodiazepine hypnotic within the prior 730 days under the CVS Caremark‑administered prescription benefit; if met, the branded drug will be paid without prior authorization.
If requirement not met	Claim will reject indicating prior authorization is required; prior authorization may be granted if the member has (a) inadequate treatment response after at least a 30‑day trial of at least one generic non‑benzodiazepine hypnotic, (b) a documented contraindication or potential drug interaction prohibiting trial of at least one generic non‑benzodiazepine hypnotic, or (c) documented intolerance to at least one generic non‑benzodiazepine hypnotic.