CurrentUnitedHealthcarePolicy N/A

Sedative-Hypnotics (North Carolina) Prior Authorization Form - Community Planopen_in_new

A prior authorization request form used by UnitedHealthcare Community Plan (NC) to document beneficiary, prescriber and clinical information required to approve non-preferred sedative-hypnotic drugs and requests to exceed quantity limits (greater than 15 per 30 days) or therapy durations up to a 180-day maximum.

Policy Summary

PayerUnitedHealthcare

PolicySedative-Hypnotics (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeForm / Prior Authorization

Effective Date

Next Review Date

Key ActionProviders must complete beneficiary, prescriber, and drug information; attest with prescriber signature and date; document failure of two preferred drugs or other listed reasons for exception and provide clinical details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified.

15/30dDefault Quantity Limit

180 daysMaximum Therapy Duration

2Preferred Failures Required

Coverage Summary

This prior authorization form is used by UnitedHealthcare Community Plan (NC) to document beneficiary, prescriber, and clinical information required to approve requests for non-preferred sedative-hypnotic drugs. The form also supports requests to exceed quantity limits (greater than 15 per 30 days) or to authorize therapy durations up to a maximum of 180 days.

Non-Preferred Drug Exception Criteria (Initial)

Non-Preferred Drug Exception Criteria

Request for non-preferred sedative-hypnotic when preferred drugs have failed or are contraindicated. Provide supporting clinical information for one or more reasons below:

ANY of the following

Failed two preferred drug(s). List preferred drugs failed and indicate reason(s) (allergy, drug-drug interaction).
Form requires listing drugs and specifying allergic reaction or interaction.
Previous episode of an unacceptable side effect or therapeutic failure with preferred drug(s).
Provide clinical information describing side effect or therapeutic failure.
Clinical contraindication, co-morbidity, or unique patient circumstance as a contraindication to preferred drug(s).
Provide clinical information describing contraindication/co-morbidity.
Age specific indications.
Provide patient age and explanation.
Unique clinical indication supported by FDA approval or peer-reviewed literature.
Explain indication and provide a general reference.
Unacceptable clinical risk associated with therapeutic change.
Explain the unacceptable risk.

Criteria for Quantity Limits (Exceeding 15 per 30 days)

To support a request to exceed a quantity limit of 15 per 30 days, check applicable items and provide documentation.

ALL of the following

ALL of the following
- Non-pharmacologic therapy requirement: Beneficiary has received information on good sleep hygiene and had a documented trial (at least 3 weeks) of non-pharmacological therapies (e.g., stimulus control, sleep restriction, sleep hygiene measures and relaxation therapy).trial >= 3 weeks
If chronic secondary or comorbid insomnia
- Underlying psychiatric illness associated with insomnia.
- Underlying medical illness associated with insomnia (e.g., chronic pain associated with cancer, inflammatory arthritis).
- Sleep disorder such as restless legs syndrome, sleep-related breathing disorder, sleep-related movement disorder, or circadian rhythm disorder.
Beneficiary is being discontinued from a sedative-hypnotic and tapering is required to prevent symptoms of withdrawal.
Beneficiary is being actively assessed for a diagnosis of chronic primary or secondary/co-morbid insomnia (Do not check 'yes' if diagnosis of chronic primary insomnia is already present).

Provider Actions & Documentation Requirements

Prior Authorization

Submit completed prior authorization form for non-preferred sedative-hypnotics

Providers must complete beneficiary, prescriber, and drug information on the prior authorization form, including drug name, strength, quantity per 30 days, and length of therapy. The form requires documentation that two preferred drugs have failed (list preferred drugs failed and indicate allergy or drug–drug interaction if applicable) or another specified reason for exception, and must include clinical details supporting the selected reason(s).

Prior Authorization

Document justification to exceed quantity limits

To request quantities exceeding 15 per 30 days, document that the beneficiary meets one or more criteria on the form: diagnosis of chronic primary insomnia lasting one month or longer; a documented trial of non-pharmacologic therapies for at least 3 weeks (e.g., stimulus control, sleep restriction, sleep hygiene measures, relaxation therapy); diagnosis and active evaluation/treatment of a relevant comorbid or secondary insomnia condition (psychiatric, medical, or specific sleep disorders); or that tapering is required to prevent withdrawal. Include supporting clinical documentation for the chosen justification(s).

Documentation Required

Mandatory prescriber signature

Prescriber signature is mandatory on the form and certifies that the information provided is accurate and complete; the signature and date are required and absence may render the request incomplete or invalid.

Background

The form collects required clinical information to support prior authorization requests for non-preferred sedative-hypnotics, including documentation that preferred drugs have failed or are contraindicated (e.g., listing two failed preferred drugs and reasons such as allergy or drug-drug interaction) and clinical details about prior unacceptable side effects or therapeutic failure.

For requests to exceed quantity or duration limits, the form emphasizes documentation of a trial of non-pharmacologic therapies (at least 3 weeks where applicable), evaluation/treatment of relevant comorbid conditions, or the need for tapering to prevent withdrawal. The prescriber’s signature is mandatory to attest to the accuracy of the information.

Clinical Evidence / Supporting Rationale

No discrete clinical trial metrics, citations, or evidence items were provided within the form brief. Per the Non-Preferred Drug Exception Criteria on the form, unique clinical indications should be supported by FDA approval or peer-reviewed literature when applicable, and such supporting documentation may be submitted with the PA request.