Texas Prior Authorization Program Clinical Edit Criteria

Transcription

1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class COX-2 Inhibitors Clinical Edit Information Included in this Document COX-2 Inhibitors Celebrex Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical edit COX-2 Inhibitors Mobic Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. vember 18, 2011 Copyright 2011 Health Information Designs, LLC 1

2 COX-2 Inhibitors Revision tes Added a new section to specify the drugs requiring prior authorization for each form of COX-2 Inhibitors In the Clinical Edit Criteria Logic and Clinical Edit Criteria Logic Diagram sections for Celebrex, clarified wording associated with step 6 In the Clinical Edit Criteria Logic and Clinical Edit Criteria Logic Diagram sections for Mobic, clarified wording associated with step 5 In the Clinical Edit Supporting Tables section for Celebrex, revised tables to specify the diagnosis codes pertinent to steps 3, 4, and 8 of the logic diagram In the Clinical Edit Supporting Tables section for Celebrex, revised tables to specify the drug names and s pertinent to steps 5, 6, 7, 9, and 10 of the logic diagram In the Clinical Edit Supporting Tables section for Mobic, revised tables to specify the diagnosis codes pertinent to steps 3, 7, and 10 of the logic diagram In the Clinical Edit Supporting Tables section for Mobic, revised tables to specify the drug names and s pertinent to steps 4, 5, 6, 8, and 9 of the logic diagram vember 18, 2011 Copyright 2011 Health Information Designs, LLC 2

3 COX-2 Inhibitors Celebrex Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization CELEBREX 50 MG CAPSULE CELEBREX 100 MG CAPSULE CELEBREX 200 MG CAPSULE CELEBREX 400 MG CAPSULE vember 18, 2011 Copyright 2011 Health Information Designs, LLC 3

4 COX-2 Inhibitors Celebrex Clinical Edit Criteria Logic 1. Is the client less than (<) 18 years of age? [ ] (Deny) [ ] (Go to #2) 2. Is the client greater than or equal to ( ) 60 years of age? [ ] (Approve 365 days) [ ] (Go to #3) 3. diagnosis of FAP or ankylosing spondylitis in the last 730 days? [ ] (Approve 365 days) [ ] (Go to #4) 4. diagnosis of PUD or GI bleed in the last 730 days? [ ] (Approve 365 days) [ ] (Go to #5) 5. history of warfarin therapy for 30 days in the last 45 days? [ ] (Approve 365 days) [ ] (Go to #6) 6. history of corticosteroid therapy for greater than or equal to ( ) 35 days in the last 90 days? [ ] (Approve 365 days) [ ] (Go to #7) 7. Has the client taken high dose NSAID therapy for 30 days in the last 45 days? [ ] (Approve 365 days) [ ] (Go to #8) 8. diagnosis of RA, JRA, or OA in the last 730 days? [ ] (Approve 365 days) [ ] (Go to #9) 9. history of a DMARD agent for 30 days in the last 60 days? [ ] (Approve 365 days) [ ] (Go to #10) 10. history of 2 or more NSAID agents for 30 days in the last 180 days? [ ] (Approve 365 days) [ ] (Deny) vember 18, 2011 Copyright 2011 Health Information Designs, LLC 4

5 COX-2 Inhibitors Celebrex Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client < 18 years of age? Is the client 60 years of age? diagnosis of FAP or ankylosing spondylitis in the last 730 days? Step 4 Deny Request diagnosis of PUD or GI bleed in the last 730 days? Step 6 history of corticosteroid therapy for 35 days in the last 90 days? Step 5 history of warfarin therapy for 30 days in the last 45 days? Step 7 Step 8 Has the client taken high dose NSAID therapy for 30 days in the last 45 days? diagnosis of RA, JRA, or OA in the last 730 days? Step 10 Step 9 history of 2 or more NSAID agents for 30 days in the last 180 days? history of a DMARD agent for 30 days in the last 60 days? Deny Request vember 18, 2011 Copyright 2011 Health Information Designs, LLC 5

6 COX-2 Inhibitors Celebrex Clinical Edit Criteria Supporting Tables Step 3 (diagnosis of FAP or ankylosing spondylitis) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 2113 BENIGN NEOPLASM LG BOWEL 7200 ANKYLOSING SPONDYLITIS Step 4 (diagnosis of PUD or GI bleed) Required diagnosis: 1 Look back timeframe: 730 days PUD and GI Bleed Diagnoses ICD-9 Code Description 531 GASTRIC ULCER 5310 ACUTE GASTRIC ULCER WITH HEMORRHAGE AC STOMACH ULCER W HEM AC STOMAC ULC W HEM-OBST 5311 ACUTE GASTRIC ULCER WITH PERFORATION AC STOMACH ULCER W PERF AC STOM ULC W PERF-OBST 5312 ACUTE GASTRIC ULCER WITH HEMORRHAGE AND PERFORATION AC STOMAC ULC W HEM/PERF AC STOM ULC HEM/PERF-OBS 5313 ACUTE GASTRIC ULCER WITHOUT MENTION OF HEMORRHAGE OR PERFORATION ACUTE STOMACH ULCER NOS AC STOMACH ULC NOS-OBSTR 5314 CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE CHR STOMACH ULC W HEM CHR STOM ULC W HEM-OBSTR 5315 CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH PERFORATION CHR STOMACH ULCER W PERF CHR STOM ULC W PERF-OBST 5316 CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE AND PERFORATION vember 18, 2011 Copyright 2011 Health Information Designs, LLC 6

7 ICD-9 Code Description Step 4 (diagnosis of PUD or GI bleed) Required diagnosis: 1 Look back timeframe: 730 days PUD and GI Bleed Diagnoses CHR STOMACH ULC HEM/PERF CHR STOM ULC HEM/PERF-OB 5317 CHRONIC GASTRIC ULCER WITHOUT MENTION OF HEMORRHAGE OR PERFORATION CHR STOMACH ULCER NOS CHR STOMACH ULC NOS-OBST 5319 GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT MENTION OF HEMORRHAGE OR PERFORATION STOMACH ULCER NOS STOMACH ULCER NOS-OBSTR 532 DUODENAL ULCER 5320 ACUTE DUODENAL ULCER WITH HEMORRHAGE AC DUODENAL ULCER W HEM AC DUODEN ULC W HEM-OBST 5321 ACUTE DUODENAL ULCER WITH PERFORATION AC DUODENAL ULCER W PERF AC DUODEN ULC PERF-OBSTR 5322 ACUTE DUODENAL ULCER WITH HEMORRHAGE AND PERFORATION AC DUODEN ULC W HEM/PERF AC DUOD ULC HEM/PERF-OBS 5323 ACUTE DUODENAL ULCER WITHOUT MENTION OF HEMORRHAGE OR PERFORATION ACUTE DUODENAL ULCER NOS AC DUODENAL ULC NOS-OBST 5324 CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH HEMORRHAGE CHR DUODEN ULCER W HEM CHR DUODEN ULC HEM-OBSTR 5325 CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH PERFORATION CHR DUODEN ULCER W PERF CHR DUODEN ULC PERF-OBST 5326 CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH HEMORRHAGE AND PERFORATION CHR DUODEN ULC HEM/PERF CHR DUOD ULC HEM/PERF-OB 5327 CHRONIC DUODENAL ULCER WITHOUT MENTION OF HEMORRHAGE OR PERFORATION vember 18, 2011 Copyright 2011 Health Information Designs, LLC 7

8 ICD-9 Code Description CHR DUODENAL ULCER NOS Step 4 (diagnosis of PUD or GI bleed) Required diagnosis: 1 Look back timeframe: 730 days PUD and GI Bleed Diagnoses CHR DUODEN ULC NOS-OBSTR 5329 DUODENAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT MENTION OF HEMORRHAGE OR PERFORATION DUODENAL ULCER NOS DUODENAL ULCER NOS-OBSTR 533 PEPTIC ULCER SITE UNSPECIFIED 5330 ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE AC PEPTIC ULCER W HEMORR AC PEPTIC ULC W HEM-OBST 5331 ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH PERFORATION AC PEPTIC ULCER W PERFOR AC PEPTIC ULC W PERF-OBS 5332 ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE AND PERFORATION AC PEPTIC ULC W HEM/PERF AC PEPT ULC HEM/PERF-OBS 5333 ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITHOUT MENTION OF HEMORRHAGE AND PERFORATION ACUTE PEPTIC ULCER NOS AC PEPTIC ULCER NOS-OBST 5334 CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE CHR PEPTIC ULCER W HEM CHR PEPTIC ULC W HEM-OBS 5335 CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH PERFORATION CHR PEPTIC ULCER W PERF CHR PEPTIC ULC PERF-OBST 5336 CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE AND PERFORATION CHR PEPT ULC W HEM/PERF CHR PEPT ULC HEM/PERF-OB 5337 CHRONIC PEPTIC ULCER OF UNSPECIFIED SITE WITHOUT MENTION OF HEMORRHAGE OR PERFORATION CHRONIC PEPTIC ULCER NOS CHR PEPTIC ULCER NOS-OBS vember 18, 2011 Copyright 2011 Health Information Designs, LLC 8

9 ICD-9 Code Description Step 4 (diagnosis of PUD or GI bleed) Required diagnosis: 1 Look back timeframe: 730 days PUD and GI Bleed Diagnoses 5339 PEPTIC ULCER OF UNSPECIFIED SITE UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT MENTION OF HEMORRHAGE OR PERFORATION PEPTIC ULCER NOS PEPTIC ULCER NOS-OBSTRUC 534 GASTROJEJUNAL ULCER 5340 ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE AC GASTROJEJUNAL MARGINAL ULCER W HEM AC GASTROJEJUNAL ULC W HEM-OBST, 5341 ACUTE GASTROJEJUNAL ULCER WITH PERFORATION AC GASTROJEJUNAL ULCER W PERF, AC GASTROJEJUNAL ULC W PERF-OBS 5342 ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE AND PERFORATION AC GASTROJEJUNAL ULC W HEM/PERF AC GASTROJEJUNAL ULC HEM/PERF-OBS 5343 ACUTE GASTROJEJUNAL ULCER WITHOUT MENTION OF HEMORRHAGE OR PERFORATION AC GASTROJEJUNAL ULCER NOS AC GASTROJEJUNAL ULC NOS-OBST 5344 CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH HEMORRHAGE CHR GASTROJEJUNAL ULCER W HEM CHR GASTROJEJUNAL ULC W HEM-OBS 5345 CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH PERFORATION CHR GASTROJEJUNAL ULC W PERF CHR GASTROJEJUNAL ULC PERF-OBST 5346 CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH HEMORRHAGE AND PERFORATION CHR GASTROJEJUNAL ULC HEM/PERF CHR GASTROJEJUNAL ULC HEM/PERF-OB 5347 CHRONIC GASTROJEJUNAL ULCER WITHOUT MENTION OF HEMORRHAGE OR PERFORATION CHR GASTROJEJUNAL ULCER NOS CHR GASTROJEJUNAL ULC NOS-OBS 5349 GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT MENTION OF HEMORRHAGE OR PERFORATION GASTROJEJUNAL ULCER NOS GASTROJEJUN ULC NOS-OBST vember 18, 2011 Copyright 2011 Health Information Designs, LLC 9

10 Step 4 (diagnosis of PUD or GI bleed) Required diagnosis: 1 Look back timeframe: 730 days PUD and GI Bleed Diagnoses ICD-9 Code Description 578 GASTROINTESTINAL HEMORRHAGE 5780 HEMATEMESIS 5781 BLOOD IN STOOL 5789 GASTROINTEST HEMORR NOS Step 5 (history of warfarin therapy for 30 days) Look back timeframe: 45 days Warfarin Therapies COUMADIN 1 MG TABLET COUMADIN 2 MG TABLET COUMADIN 2.5 MG TABLET COUMADIN 3 MG TABLET COUMADIN 4 MG TABLET COUMADIN 5 MG TABLET COUMADIN 5 MG VIAL COUMADIN 6 MG TABLET COUMADIN 7.5 MG TABLET COUMADIN 10 MG TABLET JANTOVEN 1 MG TABLET JANTOVEN 2 MG TABLET JANTOVEN 2.5 MG TABLET JANTOVEN 3 MG TABLET JANTOVEN 4 MG TABLET JANTOVEN 5 MG TABLET JANTOVEN 6 MG TABLET JANTOVEN 7.5 MG TABLET JANTOVEN 10 MG TABLET WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM 4 MG TABLET vember 18, 2011 Copyright 2011 Health Information Designs, LLC 10

11 Step 5 (history of warfarin therapy for 30 days) Look back timeframe: 45 days Warfarin Therapies WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM 10 MG TABLET Step 6 (history of a corticosteroid therapy for 35 days) Look back timeframe: 90 days Corticosteroid Therapies BAYCADRON 0.5 MG/5 ML ELIXIR CELESTONE 0.6 MG/5 ML SOLUTION CELESTONE SOLUSPAN 6 MG/ML CORTEF 5 MG TABLET CORTEF 10 MG TABLET CORTEF 20 MG TABLET CORTISONE 25 MG TABLET DEPO-MEDROL 40 MG/ML VIAL DEPO-MEDROL 80 MG/ML VIAL DEXAMETHASONE 0.5 MG/5 ML ELX DEXAMETHASONE 0.5 MG/5 ML LIQ DEXAMETHASONE 1 MG/1 ML SOLN DEXAMETHASONE 0.5 MG TABLET DEXAMETHASONE 0.75 MG TABLET DEXAMETHASONE 1 MG TABLET DEXAMETHASONE 1.5 MG TABLET DEXAMETHASONE 2 MG TABLET DEXAMETHASONE 4 MG TABLET DEXAMETHASONE 6 MG TABLET DEXAMETHASONE 4 MG/ML VIAL DEXAMETHASONE 20 MG/5 ML VIAL DEXAMETHASONE 120 MG/30 ML VL DEXPAK 6 DAY 1.5 MG TABLET DEXPAK 10 DAY 1.5 MG TABLET vember 18, 2011 Copyright 2011 Health Information Designs, LLC 11

12 Step 6 (history of a corticosteroid therapy for 35 days) Look back timeframe: 90 days Corticosteroid Therapies DEXPAK 13 DAY 1.5 MG TABLET ENTOCORT EC 3 MG CAPSULE HYDROCORTISONE 5 MG TABLET HYDROCORTISONE 10 MG TABLET HYDROCORTISONE 20 MG TABLET KENALOG MG/ML VIAL KENALOG MG/ML VIAL MEDROL 4 MG DOSEPAK MEDROL 2 MG TABLET MEDROL 4 MG TABLET MEDROL 8 MG TABLET MEDROL 16 MG TABLET MEDROL 32 MG TABLET METHYLPREDNISOLONE 4 MG DOSEPK METHYLPREDNISOLONE 4 MG TAB METHYLPREDNISOLONE 4 MG TABLET METHYLPREDNISOLONE 8 MG TAB METHYLPREDNISOLONE 16 MG TAB METHYLPREDNISOLONE 32 MG TAB METHYLPREDNISOLONE 40 MG VIAL METHYLPREDNISOLONE 40 MG/ML VL METHYLPREDNISOLONE 80 MG/ML VL METHYLPREDNISOLONE 125 MG VIAL METHYLPREDNISOLONE 500 MG VIAL METHYLPREDNISOLONE SS 1 GM VL MILLIPRED 10 MG/5 ML SOLUTION MILLIPRED 5 MG TABLET ORAPRED ODT 10 MG TABLET ORAPRED ODT 15 MG TABLET ORAPRED ODT 30 MG TABLET PEDIAPRED 6.7 MG/5 ML SOLN PREDNISOLONE 5 MG/5 ML SOLN PREDNISOLONE 6.7 MG/5 ML SOLN PREDNISOLONE 15 MG/5 ML SOLN vember 18, 2011 Copyright 2011 Health Information Designs, LLC 12

13 Step 6 (history of a corticosteroid therapy for 35 days) Look back timeframe: 90 days Corticosteroid Therapies PREDNISOLONE 15 MG/5 ML SOLN PREDNISOLONE 5 MG/5 ML SYRUP PREDNISOLONE 15 MG/5 ML SYRUP PREDNISONE 5 MG/5 ML SOLUTION PREDNISONE 1 MG TABLET PREDNISONE 2.5 MG TABLET PREDNISONE 5 MG TABLET PREDNISONE 5 MG TABLET PREDNISONE 10 MG TABLET PREDNISONE 10 MG TABLET PREDNISONE 20 MG TABLET PREDNISONE 50 MG TABLET SOLU-CORTEF 100 MG VIAL SOLU-MEDROL 500 MG VIAL SOLU-MEDROL 500 MG VIAL SOLU-MEDROL 1,000 MG VIAL SOLU-MEDROL 1 GM VIAL STERAPRED 5 MG TABLET UNIPAK STERAPRED DS 10 MG TB UNIPAK VERIPRED MG/5 ML SOLN ZEMA-PAK 6 DAY 1.5 MG TABLET ZEMA-PAK 10 DAY 1.5 MG TABLET ZEMA-PAK 13 DAY 1.5 MG TABLET Step 7 (history of a high dose NSAID therapy for 30 days) Look back timeframe: 45 days NSAID Agents ALL DAY PAIN RELIEF 220 MG TAB ALL DAY PAIN RLF 220 MG CAPLET ANAPROX DS 550 MG TABLET ARTHROTEC EC 50 MG-200 MCG TAB ARTHROTEC EC 75 MG-200 MCG TAB vember 18, 2011 Copyright 2011 Health Information Designs, LLC 13

14 Step 7 (history of a high dose NSAID therapy for 30 days) Look back timeframe: 45 days NSAID Agents CAMBIA 50 MG POWDER PACKET CATAFLAM 50 MG TABLET CHILD IBUPROFEN SUSP CHILDREN IBUPROFEN 100 MG/5 ML CHILDREN'S MEDI-PROFEN SUSP CLINORIL 200 MG TABLET DAYPRO 600 MG CAPLET DICLOFENAC POT 50 MG TABLET DICLOFENAC SOD DR 50 MG TAB DICLOFENAC SOD DR 75 MG TAB DICLOFENAC SOD EC 25 MG TAB DICLOFENAC SOD EC 50 MG TAB DICLOFENAC SOD EC 75 MG TAB DICLOFENAC SOD ER 100 MG TAB ETODOLAC 200 MG CAPSULE ETODOLAC 300 MG CAPSULE ETODOLAC 400 MG TABLET ETODOLAC 500 MG TABLET ETODOLAC ER 400 MG TABLET ETODOLAC ER 500 MG TABLET ETODOLAC ER 600 MG TABLET FELDENE 10 MG CAPSULE FELDENE 20 MG CAPSULE FENOPROFEN 600 MG TABLET FLECTOR 1.3% PATCH FLURBIPROFEN 50 MG TABLET FLURBIPROFEN 100 MG TABLET HYDROCODONE BT-IBUPROFEN TAB IBUDONE MG TABLET IBUDONE MG TABLET IBU-DROPS 40 MG/ML SUSP DRPS IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG TABLET vember 18, 2011 Copyright 2011 Health Information Designs, LLC 14

15 Step 7 (history of a high dose NSAID therapy for 30 days) Look back timeframe: 45 days NSAID Agents IBUPROFEN 400 MG TABLET IBUPROFEN 600 MG TABLET IBUPROFEN 800 MG TABLET IBUPROFEN COLD SUSPENSION IBUPROFEN COLD-SINUS CPLT IBUPROFEN JR STR 100 MG TB CHW INDOMETHACIN 25 MG CAPSULE INDOMETHACIN 50 MG CAPSULE INDOMETHACIN ER 75 MG CAPSULE INFANT IBUPROFEN SUSP DROP INFANTS IBU-DROPS SUSPENSION KETOPROFEN 50 MG CAPSULE KETOPROFEN 75 MG CAPSULE KETOPROFEN ER 200 MG CAPSULE KETOROLAC 10 MG TABLET KETOROLAC 15 MG/ML VIAL KETOROLAC 30 MG/ML VIAL KETOROLAC 60 MG/2 ML VIAL MECLOFENAMATE 50 MG CAPSULE MECLOFENAMATE 100 MG CAPSULE MEDI-PROFEN 200 MG CAPLET MEDI-PROFEN 200 MG TABLET MEFENAMIC ACID 250 MG CAPSULE NABUMETONE 500 MG TABLET NABUMETONE 750 MG TABLET NAPRELAN CR 375 MG TABLET NAPRELAN CR 500 MG TABLET NAPRELAN CR 750 MG TABLET NAPROSYN 125 MG/5 ML SUSPEN NAPROSYN 250 MG TABLET NAPROSYN 375 MG TABLET NAPROSYN EC 500 MG TABLET NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN 250 MG TABLET vember 18, 2011 Copyright 2011 Health Information Designs, LLC 15

16 Step 7 (history of a high dose NSAID therapy for 30 days) Look back timeframe: 45 days NSAID Agents NAPROXEN 375 MG TABLET NAPROXEN 500 MG TABLET NAPROXEN EC 375 MG TABLET NAPROXEN EC 500 MG TABLET NAPROXEN SODIUM 220 MG CAPLET NAPROXEN SODIUM 220 MG TABLET NAPROXEN SODIUM 275 MG TAB NAPROXEN SODIUM 550 MG TAB OXAPROZIN 600 MG TABLET OXYCODONE-IBUPROFEN TAB PENNSAID 1.5% SOLUTION PIROXICAM 10 MG CAPSULE PIROXICAM 20 MG CAPSULE PONSTEL 250 MG KAPSEALS PREVACID NAPRAPAC QC IBUPROFEN 200 MG CAPLET QC IBUPROFEN 200 MG SOFTGEL QC IBUPROFEN 200 MG TABLET QC NAPROXEN SOD 220 MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET SM IBUPROFEN 200 MG CAPLET SM IBUPROFEN 200 MG TABLET SM IBUPROFEN IB 200 MG CAPLET SOLARAZE 3% GEL SULINDAC 150 MG TABLET SULINDAC 200 MG TABLET TOLMETIN SODIUM 200 MG TAB TOLMETIN SODIUM 400 MG CAP TOLMETIN SODIUM 600 MG TAB TREXIMET MG TABLET VICOPROFEN MG TAB vember 18, 2011 Copyright 2011 Health Information Designs, LLC 16

17 Step 7 (history of a high dose NSAID therapy for 30 days) Look back timeframe: 45 days NSAID Agents VIMOVO MG TABLET VIMOVO MG TABLET VOLTAREN 1% GEL VOLTAREN-XR 100 MG TABLET ZIPSOR 25 MG CAPSULE Step 8 (diagnosis of RA, JRA, or OA) Required diagnosis: 1 Look back timeframe: 730 days RA, JRA, and OA Diagnoses ICD-9 Code Description 7140 RHEUMATOID ARTHRITIS 7141 FELTY'S SYNDROME 7142 SYST RHEUM ARTHRITIS NEC 7143 JUVENILE CHRONIC POLYARTHRITIS JUV RHEUM ARTHRITIS NOS POLYART JUV RHEUM ARTHR PAUCIART JUV RHEUM ARTHR MONOART JUV RHEUM ARTHR 7144 CHR POSTRHEUM ARTHRITIS 7148 OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES RHEUMATOID LUNG INFLAMM POLYARTHROP NEC 715 OSTEOARTHROSIS AND ALLIED DISORDERS 7150 OSTEOARTHROSIS GENERALIZED GENERAL OSTEOARTHROSIS GEN OSTEOARTHROS-HAND GENERAL OSTEOARTHROSIS 7151 OSTEOARTHROSIS LOCALIZED PRIMARY LOC PRIM OSTEOART-UNSPEC LOC PRIM OSTEOART-SHLDER LOC PRIM OSTEOART-UP/ARM LOC PRIM OSTEOART-FORARM LOC PRIM OSTEOARTH-HAND vember 18, 2011 Copyright 2011 Health Information Designs, LLC 17

18 ICD-9 Code Description LOC PRIM OSTEOART-PELVIS LOC PRIM OSTEOART-L/LEG Step 8 (diagnosis of RA, JRA, or OA) Required diagnosis: 1 Look back timeframe: 730 days RA, JRA, and OA Diagnoses LOC PRIM OSTEOARTH-ANKLE LOC PRIM OSTEOARTHR NEC 7152 OSTEOARTHROSIS LOCALIZED SECONDARY LOC 2ND OSTEOARTH-UNSPEC LOC 2ND OSTEOARTH-SHLDER LOC 2ND OSTEOARTH-UP/ARM LOC 2ND OSTEOART-FOREARM LOC 2ND OSTEOARTHRO-HAND LOC 2ND OSTEOARTH-PELVIS LOC 2ND OSTEOARTHR-L/LEG LOC 2ND OSTEOARTHR-ANKLE LOC 2ND OSTEOARTHROS NEC 7153 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY LOC OSTEOARTH NOS-UNSPEC LOC OSTEOARTH NOS-SHLDER LOC OSTEOARTH NOS-UP/ARM LOC OSTEOART NOS-FOREARM LOC OSTEOARTH NOS-HAND LOC OSTEOARTH NOS-PELVIS LOC OSTEOARTH NOS-L/LEG LOC OSTEOARTH NOS-ANKLE LOC OSTEOAR NOS-SITE NEC 7158 OSTEOARTHROSIS INVOLVING OR WITH MENTION OF MORE THAN ONE SITE BUT NOT SPECIFIED AS GENERALIZED OSTEOARTHROSIS-MULT SITE OSTEOARTHROSIS-MULT SITE 7159 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED OSTEOARTHROS NOS-UNSPEC OSTEOARTHROS NOS-SHLDER OSTEOARTHROS NOS-UP/ARM OSTEOARTHROS NOS-FOREARM OSTEOARTHROS NOS-HAND vember 18, 2011 Copyright 2011 Health Information Designs, LLC 18

19 Step 8 (diagnosis of RA, JRA, or OA) Required diagnosis: 1 Look back timeframe: 730 days RA, JRA, and OA Diagnoses ICD-9 Code Description OSTEOARTHROS NOS-PELVIS OSTEOARTHROS NOS-L/LEG OSTEOARTHROS NOS-ANKLE OSTEOARTHRO NOS-OTH SITE Step 9 (history of a DMARD agent for 30 days) Look back timeframe: 60 days DMARD Agents ARAVA 10 MG TABLET ARAVA 20 MG TABLET AZATHIOPRINE 50 MG TABLET CUPRIMINE 250 MG CAPSULE CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE 50 MG SOFTGEL CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE MODIFIED 100 MG CYCLOSPORINE MODIFIED 25 MG DEPEN 250 MG TITRATAB ENBREL 25 MG KIT ENBREL 25 MG/0.5 ML SYRINGE ENBREL 50 MG/ML SURECLICK SYR ENBREL 50 MG/ML SYRINGE GENGRAF 25 MG CAPSULE GENGRAF 100 MG CAPSULE GENGRAF 100 MG/ML SOLUTION HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA 40 MG/0.8 ML PEN HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA CROHN'S STARTER PACK HUMIRA PSORIASIS STARTER PACK vember 18, 2011 Copyright 2011 Health Information Designs, LLC 19

20 Step 9 (history of a DMARD agent for 30 days) Look back timeframe: 60 days DMARD Agents HYDROXYCHLOROQUINE 200 MG TAB IMURAN 50 MG TABLET KINERET 100 MG/0.67 ML SYR LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE 20 MG TABLET METHOTREXATE 2.5 MG TABLET METHOTREXATE 25 MG/ML VIAL METHOTREXATE 25 MG/ML VIAL NEORAL 100 MG/ML SOLUTION NEORAL 25 MG GELATIN CAPSULE NEORAL 100 MG GELATN CAPSULE PLAQUENIL 200 MG TABLET RHEUMATREX 2.5 MG TABLET SANDIMMUNE 25 MG CAPSULE SANDIMMUNE 100 MG CAPSULE SANDIMMUNE 100 MG/ML SOLN TREXALL 5 MG TABLET TREXALL 10 MG TABLET TREXALL 15 MG TABLET TREXALL 7.5 MG TABLET Step 10 (history of 2 or more NSAID agents for 30 days) Required quantity: 2 Look back timeframe: 180 days For the list of NSAID agents that pertain to this step, see the NSAID Agents table in this Supporting Tables section. te: Click the hyperlink to navigate directly to the table. vember 18, 2011 Copyright 2011 Health Information Designs, LLC 20

21 COX-2 Inhibitors (Mobic) COX-2 Inhibitors Mobic Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization MELOXICAM 7.5 MG/5 ML SUSP MELOXICAM 7.5 MG TABLET MELOXICAM 15 MG TABLET MOBIC 7.5 MG TABLET MOBIC 15 MG TABLET vember 18, 2011 Copyright 2011 Health Information Designs, LLC 21

22 COX-2 Inhibitors (Mobic) COX-2 Inhibitors Mobic Clinical Edit Criteria Logic 1. Is the client less than (<) 18 years of age? [ ] (Deny) [ ] (Go to #2) 2. Is the client greater than or equal to ( ) 60 years of age? [ ] (Approve 365 days) [ ] (Go to #3) 3. diagnosis of PUD or GI bleed in the last 730 days? [ ] (Approve 365 days) [ ] (Go to #4) 4. history of warfarin therapy for 30 days in the last 45 days? [ ] (Approve 365 days) [ ] (Go to #5) 5. Has the client had corticosteroid therapy for greater than or equal to ( ) 35 days in the last 90 days? [ ] (Approve 365 days) [ ] (Go to #6) 6. Has the client taken high dose NSAID therapy for 30 days in the last 45 days? [ ] (Approve 365 days) [ ] (Go to #7) 7. diagnosis of RA, JRA, or OA in the last 730 days? [ ] (Approve 365 days) [ ] (Go to #8) 8. history of a DMARD agent for 30 days in the last 60 days? [ ] (Approve 365 days) [ ] (Go to #9) 9. history of 2 or more NSAID agents for 30 days in the last 180 days? [ ] (Approve 365 days) [ ] (Go to #10) 10. diagnosis of FAP or ankylosing spondylitis in the last 730 days? [ ] (Deny) [ ] (Approve 365 days) vember 18, 2011 Copyright 2011 Health Information Designs, LLC 22

23 COX-2 Inhibitors (Mobic) COX-2 Inhibitors Mobic Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client < 18 years of age? Is the client 60 years of age? diagnosis of PUD or GI bleed in the last 730 days? Step 4 Deny Request history of warfarin therapy for 30 days in the last 45 days? Step 6 Has the client taken high dose NSAID therapy for 30 days in the last 45 days? Step 5 history of corticosteroid therapy for 35 days in the last 90 days? Step 7 Step 8 diagnosis of RA, JRA, or OA in the last 730 days? history of a DMARD agent for 30 days in the last 60 days? Step 10 Step 9 diagnosis of FAP or ankylosing spondylitis in the last 730 days? history of 2 or more NSAID agents for 30 days in the last 180 days? Deny Request vember 18, 2011 Copyright 2011 Health Information Designs, LLC 23

24 COX-2 Inhibitors (Mobic) COX-2 Inhibitors Mobic Clinical Edit Criteria Supporting Tables Step 3 (diagnosis of PUD or GI bleed) Required diagnosis: 1 Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the PUD and GI Bleed Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 4 (history of warfarin therapy for 30 days) Look back timeframe: 45 days For the list of therapies that pertain to this step, see the Warfarin Therapies table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 5 (history of corticosteroid therapy for 35 days) Look back timeframe: 90 days For the list of therapies that pertain to this step, see the Corticosteroid Therapies table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 6 (history of a high dose of NSAID therapy for 30 days) Look back timeframe: 45 days For the list of therapies that pertain to this step, see the High Dose NSAID Therapies table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. vember 18, 2011 Copyright 2011 Health Information Designs, LLC 24

25 Mobic (Mobic) Step 7 (diagnosis of RA, JRA, or OA) Required diagnosis: 1 Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the RA, JRA, and OA Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 8 (history of a DMARD agent for 30 days) Look back timeframe: 60 days For the list of agents that pertain to this step, see the DMARD Agents table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 9 (history of 2 or more NSAID agents for 30 days) Required quantity: 2 Look back timeframe: 180 days For the list of agents that pertain to this step, see the NSAID Agents table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 10 (diagnosis of FAP or ankylosing spondylitis) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 2113 BENIGN NEOPLASM LG BOWEL 7200 ANKYLOSING SPONDYLITIS vember 18, 2011 Copyright 2011 Health Information Designs, LLC 25

26 COX-2 Inhibitors (Mobic) COX-2 Inhibitors Clinical Edit Criteria References 1. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs. N Engl J Med 1999; 340(24): Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med 1998; 105(1B):31S 38S. 3. Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343: Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: The CLASS study: A randomized controlled trial. JAMA 2000; 284: American Pain Society. Guideline for the management of pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. Clinical Practice Guidelines. 2, Peterson WL, Cryer B. COX-1-sparing NSAIDs Is the enthusiasm justified? JAMA 1999; 282(20): Lanza FL. A guideline for the treatment and prevention of NSAID-induced ulcers. Am J Gastroenterol 1998; 93(11): American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2001 update. Arthritis & Rheumatism 2002; 46(2): US Department of Health and Human Services. MedWatch safety alerts for human medical products. Available at vember 18, 2011 Copyright 2011 Health Information Designs, LLC 26

27 COX-2 Inhibitors (Mobic) Publication History The Publication History records the publication iterations and revisions to this document. tes for the most current revision are also provided in the Revision tes on the first page of this document. Publication Date tes 01/31/2011 Initial publication and posting to website 11/18/2011 Added a new section to specify the drugs requiring prior authorization for each form of COX-2 Inhibitors In the Clinical Edit Criteria Logic and Clinical Edit Criteria Logic Diagram sections for Celebrex, clarified wording associated with step 6 In the Clinical Edit Criteria Logic and Clinical Edit Criteria Logic Diagram sections for Mobic, clarified wording associated with step 5 In the Clinical Edit Supporting Tables section for Celebrex, revised tables to specify the diagnosis codes pertinent to steps 3, 4, and 8 of the logic diagram In the Clinical Edit Supporting Tables section for Celebrex, revised tables to specify the drug names and s pertinent to steps 5, 6, 7, 9, and 10 of the logic diagram In the Clinical Edit Supporting Tables section for Mobic, revised tables to specify the diagnosis codes pertinent to steps 3, 7, and 10 of the logic diagram In the Clinical Edit Supporting Tables section for Mobic, revised tables to specify the drug names and s pertinent to steps 4, 5, 6, 8, and 9 of the logic diagram vember 18, 2011 Copyright 2011 Health Information Designs, LLC 27