CurrentNeighborhood Health Plan of Rhode IslandPolicy 1975 A 12 2022

Acamprosate Calcium Pa Policy 1975 A 12 2022

Prior authorization policy for acamprosate calcium delayed-release tablets covering use for maintenance of abstinence in patients with alcohol dependence as part of comprehensive management including psychosocial support. Defines initial and continuation criteria for coverage and acceptable reasons for restart after relapse.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAcamprosate Calcium Pa Policy 1975 A 12 2022

Policy CodePolicy 1975 A 12 2022

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for acamprosate calcium; document DSM-5 diagnosis, patient abstinence at initiation, and inclusion in a comprehensive psychosocial management program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — has_material_change=false.

1Indication covered (alcohol dependence maintenance of abstinence)

3Core approval criteria

Coverage Summary

Prior authorization policy for acamprosate calcium delayed-release tablets covering use for maintenance of abstinence in patients with alcohol dependence as part of comprehensive management including psychosocial support. Defines initial and continuation criteria for coverage and acceptable reasons for restart after relapse.

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Initial Therapy Criteria (Prior Authorization)

Initial Prior Authorization — Covered when ALL criteria are met

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

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.
Reflects FDA indication that efficacy demonstrated in patients abstinent at treatment initiation.

Continuation Therapy Criteria

Continuation Therapy — Covered when ALL criteria are met

The request is for continuation of therapy

Documented 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).

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required for acamprosate calcium; coverage is granted only when criteria (DSM-5 diagnosis, psychosocial support, abstinence at initiation) are met.

Documentation Required

Document abstinence and psychosocial program

Providers must document DSM-5 diagnosis of alcohol use disorder, evidence that the patient is or will be abstinent at treatment initiation, and that therapy is part of a comprehensive management program including psychosocial support.

Documentation Required

Document clinical response for continuation

For continuation requests, providers must document positive clinical response (examples: abstinence, increased abstinent days, decreased heavy drinking episodes, improved physical health or psychosocial functioning).

Clinical Evidence & Background

Acamprosate calcium delayed-release tablets are FDA-indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. Treatment should be part of a comprehensive management program that includes psychosocial support. The efficacy has not been demonstrated in patients who have not achieved abstinence prior to starting treatment or in polysubstance abusers.

Acamprosate calcium package insert (Zydus Pharmaceuticals), December 2021

Definitions

termAlcohol use disorder

definitionDiagnosis as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).