Prior Authorization Form
Benzodiazepine Agents
Access this PA form at: https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_Benzodiazepines_PA_Request_Form.pdf
If the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.
Member Information
LAST NAME:
FIRST NAME:
ID NUMBER:
DATE OF BIRTH:
–
–
Medicaid Prescriber Information
LAST NAME:
FIRST NAME:
OFFICE ADDRESS:
CITY:
STATE:
NPI NUMBER:
DEA NUMBER:
PHONE NUMBER:
FAX NUMBER:
–
–
ZIP:
–
Is the prescriber a TennCare provider with a Medicaid ID?
Yes
No
Is the prescriber a single-patient contract holder for this patient?
Yes
No
Is the patient currently a resident in a long-term care facility?
Yes
No
–
If YES, what is the name of the facility? __________________________________________
Requested Benzodiazepine Agents (NOTE: TennCare covers a quantity limit of 14 tablets/30 days on all sedative hypnotic agents.)
Preferred
Non-Preferred
SPECIFY: ___________________________________
®
alprazolam (generic for Xanax )
®
chlordiazepoxide (generic for Librium )
clorazepate (generic for Tranxene®)
Diastat®
diazepam (generic for Valium®)
lorazepam (generic for Ativan®)
DOSAGE FORM:
STRENGTH:
COMPOUND:
Yes
No
DIRECTIONS:
DURATION OF THERAPY REQUESTED:
Anti-anxiety Agents: alprazolam, chlordiazepoxide, clorazepate, diazepam, lorazepam, alprazolam ER, alprazolam ODT, Ativan®, oxazepam, Tranxene-T®, Valium®,
Xanax ®, Xanax ER ®
Anticonvulsants: clonazepam, clonazepam ODT, Diastat®, diazepam rectal gel, Klonopin®, Onfi®
Sedative hypnotic agents: Doral®, estazolam, flurazepam, Halcion®, quazepam, Restoril®, temazepam, triazolam
Clinical Criteria Documentation
1.
Diagnosis:
Anxiety Disorder
Acute Muscle Spasms
Chronic Muscle Spasms
Panic Disorder
Insomnia
Other: _________________________
Epilepsy
1a.
If requesting for insomnia diagnosis, have other insomnia related disorders been ruled out?
(e.g., movement, breathing or psychiatric disorders and medication)
**Please note medical documentation may be requested **
If requesting an agent for the diagnosis of Seizure/Epilepsy Disorder, please skip to question 3.
Continued on next page. Signature MUST be submitted on page 2.
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.
If you have received this transmission in error, please immediately notify us by telephone and return the original message to
TennCare Pharmacy Program, c/o Magellan Health Services, 1st Floor South, 14100 Magellan Plaza, Maryland Heights, MO 63043.
Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
© 2016, Magellan Health Services. All Rights Reserved.
Revision History: 07/01/2017
Page 1 of 2
Seizure Disorder
Yes
No
Prior Authorization Form
Benzodiazepine Agents
Access this PA form at https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_Benzodiazepines_PA_Request_Form.pdf
PATIENT NAME:
DATE OF BIRTH:
–
2.
–
What non-pharmacological therapies has the recipient tried?
Applied Relaxation
Cognitive Behavioral
Mindfulness-based Therapy
Muscle Relaxation
Short-term
Psychodynamic
Psychotherapy
Stimulus Control
Sleep Hygiene Measures
Sleep restriction
Worry Exposure
Other:
_____________________
2a. How long were the non-pharmacological therapies tried? ________________________
3.
What preferred agents has the patient tried? Please list below:
Visit TennCare.MagellanHealth.com for preferred Anticonvulsants and/or Sedative Hypnotic Agents
Drug
4.
Length of Trial
Reason for discontinuation of the drug
Controlled Substance Database (PMP) check is required on date of request. PMP was checked today?
Yes
No
List the following information for the most recent five (5) entries found on the PMP today. If no entries, enter “none”.
Date of Fill
5.
Strength
Drug
Quantity
Does the patient have a history of alcohol abuse, drug abuse or drug dependence?
If yes, is the patient in ACUTE alcohol withdrawal?
Yes
No
Day Supply
Yes
Prescriber
No
For female patients, please complete questions 6–7.
6.
7.
The use of benzodiazepines during pregnancy is contraindicated. Is the patient currently pregnant?
Yes
No
Has this patient been counseled regarding risks to the fetus if becoming pregnant while receiving this medication?
Yes
* For patients with and Intellectual or Developmental Disability, the I/DD PA worksheet MUST accompany this form.
Please note any other information pertinent to this PA request:
Prescriber Signature and Medicaid ID Number (Required)
(By signature, the Physician confirms the above information is accurate and verifiable by patient records.)
Fax This Form to: 1-866-434-5523
Mail requests to: TennCare Pharmacy Program
c/o Magellan Health Services
1st floor South, 14100 Magellan Plaza
Maryland Heights, MO 63043
Phone: 1-866-434-5524
Magellan Health Services will provide a response within 24 hours upon receipt.
© 2016, Magellan Health Services. All Rights Reserved.
Page 2 of 2
Date
No