Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 10/01/2019 Title: Silenor (doxepin)
Revision Date: Document: BI629:00
CPT Code(s): None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Silenor (doxepin) requires prior authorization.

2)    Silenor is used to treat insomnia.

3)    Silenor is covered under the pharmacy benefit.


Medical Statement

Silenor (doxepin) is considered medically necessary for members 18 years of age and older who meet the following criteria:
1) Diagnosis of insomnia AND

2) Adequate trial and failure of zolpidem or zolpidem CR unless age 65 years and older, contraindicated, or clinically significant adverse effects are experienced AND

3) Dose does not exceed 6mg/day (1 tablet/day).

 

Reauthorization is granted if prescriber documents member is responding positively to therapy and dose remains no greater than 6mg/day.


Reference

1)    Silenor Prescribing Information. Morristown, NJ: Pernix Therapeutics, LLC. March 2010.

2)    Clinical Pharmacology. Accessed online August 14, 2019.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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