[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287460-105":53,"doc-detail-287460-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","benzodiazepine-pa-form-prior-authorization","Benzodiazepine PA Form - Prior Authorization","","Benzodiazepine prior authorization form for TennCare that gathers required member and prescriber details, including demographics, provider identifiers, and confirmation of TennCare/Medicaid status and care setting. The form specifies requested benzodiazepine agents, preferred vs non-preferred choices, strength, dosage form, directions, compound indication, and therapy duration. Clinical criteria request includes diagnosis selection, non-pharmacologic therapy history, prior preferred agent trials, PMP database check, substance-use history, pregnancy and fetal risk counseling questions, and prescriber signature with fax submission details.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/benzodiazepine-pa-form-prior-authorization/287460/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/benzodiazepine-pa-form-prior-authorization/287460.png","ImageObject",442,249,{"name":88,"@type":89},"Putri","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required from the member on this PA form?","Question",{"text":108,"@type":109},"The form requires member name, insurance ID, date of birth, street address, and city/state/ZIP.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should the requested benzodiazepine agents be documented?",{"text":113,"@type":109},"Select preferred or non-preferred agents, specify the agent(s), and provide strength, dosage form, directions, whether it is a compound, and the requested duration of therapy.",{"name":115,"@type":106,"acceptedAnswer":116},"What additional clinical checks are required as part of this prior authorization?",{"text":117,"@type":109},"The prescriber must document diagnosis and prior non-pharmacological therapies, list prior preferred agents with trial details and reasons for discontinuation, confirm a PMP database check and list the most recent entries, and answer substance-use and (if applicable) pregnancy and fetal-risk counseling questions.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287460,1790197576,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Access this PA form at: [https://optumrx.com/oe_tenncare/prescriber](https://optumrx.com/oe_tenncare/prescriber)  \nIf the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.  \n\n| Member Information (required) |  |  | Prescriber Information (required) |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Name: |  |  | Provider Name: |  |  |  |\n| Insurance ID\\#: |  |  | NPI\\#: |  | DEA\\#: |  |\n| Date of Birth: |  |  | Specialty: |  |  |  |\n| Street Address: |  |  | Office Phone: |  | Office Fax: |  |\n| City: | State: | Zip: | Office Street Address: |  |  |  |\n| Phone: |  |  | City: | State: |  | Zip: |\n|  |  |  | Is the prescribera 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?   |  |  |  |\n\n\n| Requested Benzodiazepine Agents (NOTE: TennCare covers a quantity limit of 14 tablets/30 days on all sedative hypnotic agents.) |  |\n| --- | --- |\n| Preferred | Non-Preferred |\n|  alprazolam (generic for Xanax®) |  SPECIFY:   |\n|  chlordiazepoxide (generic for Librium®) |  |\n|  clorazepate (generic for Tranxene®) |  |\n|  diazepam (generic for Valium®) |  |\n|  lorazepam (generic for Ativan®) |  |\n\nSTRENGTH:   DOSAGE FORM:   DIRECTIONS:    \nCOMPOUND:  Yes  No DURATION OF THERAPY REQUESTED:    \n\n| Anti-anxiety Agents: alprazolam, chlordiazepoxide, clorazepate, diazepam, lorazepam, alprazolam ER, alprazolam ODT, Ativan®, oxazepam, Tranxene-T®, Valium®, Xanax ®, Xanax ER\u003Cbr>® |\n| --- |\n| Anticonvulsants: clonazepam, clonazepam ODT, Diastat®, diazepam rectal gel, Klonopin®, Onfi® |\n| Sedative hypnotic agents: Doral®, estazolam, flurazepam, Halcion®, quazepam, Restoril®, temazepam, triazolam |\n\nClinical Criteria Documentation  \n1. Diagnosis:  \n Anxiety Disorder  Acute Muscle Spasms  Chronic Muscle Spasms  Epilepsy  Seizure Disorder  \n Panic Disorder  Insomnia  Other:    \n1a. If requesting for insomnia diagnosis, have other insomnia related disorders been ruled out?  Yes  No  \n(e.g., movement, breathing or psychiatric disorders and medication)  \n**Please note medical documentation may be requested **  \nIf requesting an agent for the diagnosis of Seizure/Epilepsy Disorder, please skip to question 3.  \nContinued on next page. Signature MUST be submitted on page 2 .  \nPATIENT NAME:  \nDATE OF BIRTH:  \n–  \n|  |  |\n| --- | --- |\n\n|  |  |\n| --- | --- |\n\n–  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n2. What non-pharmacological therapies has the recipient tried?  \n Applied Relaxation  Cognitive Behavioral  Mindfulness-based Therapy  Muscle Relaxation  Worry Exposure  \n Short-term  Stimulus Control  Sleep Hygiene Measures  Sleep restriction  Other:  \nPsychodynamic  \n_____________________  \nPsychotherapy  \n2a. How long were the non-pharmacological therapies tried?    \n3. What preferred agents has the patient tried? Please list below:  \nVisit [https://optumrx.com/oe](https://optumrx.com/oe) tenncare/prescriber for preferred Anticonvulsants and/or Sedative Hypnotic Agents  \n\n| _\u003Cbr>Drug | Strength | Length of Trial | Reason for discontinuation of the drug |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\n4. 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”.  \n\n| Date of Fill | Drug | Quantity | Day Supply | Prescriber |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\n5. Does the patient have a history of alcohol abuse, drug abuse or drug dependence?  Yes  No If yes, is the patient in ACUTE alcohol withdrawal?  Yes  No  \nFor female patients, please complete questions 6–7.  \n6. The","cbCaichspDPhdXOC","https://ap.wps.com/l/cbCaichspDPhdXOC","pdf",1135303,"English","# Member Information (Required)\n# Prescriber Information (Required)\n# Requested Benzodiazepine Agents\n# Clinical Criteria Documentation\n## Diagnosis\n## Non-Pharmacological Therapies\n## Preferred Agents Tried\n## Controlled Substance Database (PMP) Check\n## Substance-Use History and Pregnancy Questions\n# Submission and Signature Requirements","[{\"question\":\"What information is required from the member on this PA form?\",\"answer\":\"The form requires member name, insurance ID, date of birth, street address, and city/state/ZIP.\"},{\"question\":\"How should the requested benzodiazepine agents be documented?\",\"answer\":\"Select preferred or non-preferred agents, specify the agent(s), and provide strength, dosage form, directions, whether it is a compound, and the requested duration of therapy.\"},{\"question\":\"What additional clinical checks are required as part of this prior authorization?\",\"answer\":\"The prescriber must document diagnosis and prior non-pharmacological therapies, list prior preferred agents with trial details and reasons for discontinuation, confirm a PMP database check and list the most recent entries, and answer substance-use and (if applicable) pregnancy and fetal-risk counseling questions.\"}]","Benzodiazepine PA Form - Prior Authorization | PDF",1789632354]