acamprosate calcium — CareFirst (Caremark)

Initial criteria

• Patient has a diagnosis of alcohol use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
• Requested drug will be used as part of a comprehensive management program that includes psychosocial support.
• Patient is, or will be, abstinent from alcohol at treatment initiation.

Reauthorization criteria

• Patient has a diagnosis of alcohol use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
• Requested drug will be used as part of a comprehensive management program that includes psychosocial support.
• Patient meets ONE of the following: 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) to the requested drug; OR has experienced improvement on prior therapy and the requested drug will be restarted due to relapse.

Approval duration

12 months