CurrentNeighborhood Health Plan of Rhode IslandPolicy 1975-A

Acamprosate calcium prior authorization for alcohol use disorder

Prior authorization criteria for acamprosate calcium delayed-release tablets for maintenance of abstinence in patients with alcohol dependence; defines required diagnosis, treatment setting, psychosocial support, and continuation/renewal criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAcamprosate calcium prior authorization for alcohol use disorder

Policy CodePolicy 1975-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and requests must document DSM-5 diagnosis, inclusion in a comprehensive program with psychosocial support, and abstinence at treatment initiation (or meet continuation criteria).

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Covered Indication (alcohol use disorder)

3Continuation Criteria Options

Coverage Summary

Acamprosate calcium delayed-release tablets are covered with prior authorization for the maintenance of abstinence in patients with alcohol dependence. Coverage requires a documented DSM-5 diagnosis of alcohol use disorder and that treatment be provided as part of a comprehensive management program including psychosocial support. Prior authorization requires that the patient be abstinent at treatment initiation (or meet continuation criteria).

Initial Therapy Criteria (Prior Authorization)

Initial Prior Authorization - Coverage Criteria

The requested drug will be covered with prior authorization when ALL of the following criteria are met:

DSM-5 diagnosis: The patient has a diagnosis of alcohol use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Comprehensive management: The requested drug will be used as part of a comprehensive management program that includes psychosocial support.
Abstinence at initiation: The patient is, or the patient will be, abstinent from alcohol at treatment initiation.
See group note: abstinence at treatment initiation required for initial authorization.

"Abstinence at treatment initiation" means the patient is not consuming alcohol when acamprosate therapy is started; the policy requires the patient to be abstinent at initiation for initial authorization.

Continuation / Renewal Criteria

Coverage continued when ANY of the following are met:

Continuation of therapy: The request is for continuation of therapy.
Positive clinical response: The patient has achieved or maintained a positive clinical response (e.g., abstinence from alcohol; increase in abstinent days, decrease in heavy drinking episodes, improved physical health, improvements in psychosocial functioning).
Examples provided in source text.
Prior benefit and restart: The patient has experienced improvement on prior therapy and the requested drug will be restarted due to relapse.

Examples of a positive clinical response supporting continuation include sustained abstinence from alcohol, an increase in abstinent days, a decrease in heavy drinking episodes, and improved physical health or psychosocial functioning.

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Prior authorization is required for acamprosate calcium delayed-release tablets. Requests must document a DSM-5 diagnosis of alcohol use disorder, that treatment will be part of a comprehensive management program including psychosocial support, and that the patient is or will be abstinent at treatment initiation (or meets continuation criteria).

Policy number: 1975-A

Documentation Required

Clinical response documentation for continuation

For continuation or renewal, document a positive clinical response or prior benefit with evidence prompting restart due to relapse. Examples of positive clinical response include abstinence from alcohol, an increase in abstinent days, a decrease in heavy drinking episodes, improved physical health, or improvements in psychosocial functioning.

Abstinent days (increase)
Number of heavy drinking episodes (decrease)
Improved physical health
Improvements in psychosocial functioning

Clinical Evidence & Background

Acamprosate calcium delayed-release tablets are FDA-approved for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. Efficacy has not been demonstrated in patients who have not undergone detoxification or who are not abstinent at initiation, and there are insufficient data regarding efficacy in polysubstance abusers. Treatment should be provided as part of a comprehensive psychosocial support program.

References include guideline and evidence sources such as AHRQ, SAMHSA, and Micromedex; these documents were accessed in October 2022.