Texas Prior Authorization Program Clinical Edit Criteria

Size: px
Start display at page:

Download "Texas Prior Authorization Program Clinical Edit Criteria"

Transcription

1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document 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 Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated ICD-10s in Table A, page 22 January 30, 2017 Copyright Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization First Generation Label Name GCN HIC4 AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE CHLORPROMAZINE 10 MG TABLET H2GA CHLORPROMAZINE 25 MG TABLET H2GA CHLORPROMAZINE 50 MG TABLET H2GA CHLORPROMAZINE 100 MG TABLET H2GA CHLORPROMAZINE 200 MG TABLET H2GA CHLORPROMAZINE 30MG/ML CONC H2GA CHLORPROMAZINE 100MG/ML CONC H2GA FLUPHENAZINE 1 MG TABLET H2GD FLUPHENAZINE 2.5 MG TABLET H2GD FLUPHENAZINE 5 MG TABLET H2GD FLUPHENAZINE 10 MG TABLET H2GD FLUPHENAZINE 5 MG/ML CONC H2GD FLUPHENAZINE 2.5 MG/5 ML ELIX H2GD HALOPERIDOL 0.5 MG TABLET H2LH HALOPERIDOL 1 MG TABLET H2LH HALOPERIDOL 2 MG TABLET H2LH HALOPERIDOL 5 MG TABLET H2LH HALOPERIDOL 10 MG TABLET H2LH HALOPERIDOL 20 MG TABLET H2LH HALOPERIDOL 1MG/ML SOLUTION H2LH HALOPERIDOL LAC 2 MG/ML CONC H2LH LOXAPINE 5 MG CAPSULE H7UA LOXAPINE 10 MG CAPSULE H7UA LOXAPINE 25 MG CAPSULE H7UA LOXAPINE 50 MG CAPSULE H7UA LOXITANE 5 MG CAPSULE H7UA LOXITANE 10 MG CAPSULE H7UA January 30, 2017 Copyright Health Information Designs, LLC 2

3 First Generation Label Name GCN HIC4 LOXITANE 25 MG CAPSULE H7UA LOXITANE 50 MG CAPSULE H7UA MOBAN 5 MG TABLET H2LR MOBAN 10 MG TABLET H2LR MOBAN 25 MG TABLET H2LR MOBAN 50 MG TABLET H2LR ORAP 1 MG TABLET H2LG ORAP 2 MG TABLET H2LG PERPHENAZINE 2 MG TABLET H2GE PERPHENAZINE 4 MG TABLET H2GE PERPHENAZINE 8 MG TABLET H2GE PERPHENAZINE 16 MG TABLET H2GE THIORIDAZINE 10 MG TABLET H2GH THIORIDAZINE 25 MG TABLET H2GH THIORIDAZINE 50 MG TABLET H2GH THIORIDAZINE 100 MG TABLET H2GH THIOTHIXENE 1 MG CAPSULE H2LT THIOTHIXENE 2 MG CAPSULE H2LT THIOTHIXENE 5 MG CAPSULE H2LT THIOTHIXENE 10 MG CAPSULE H2LT TRIFLUOPERAZINE 1 MG TABLET H2GG TRIFLUOPERAZINE 2 MG TABLET H2GG TRIFLUOPERAZINE 5 MG TABLET H2GG TRIFLUOPERAZINE 10 MG TABLET H2GG Second Generation (Oral/Regular Acting Injectables) Label Name GCN HIC4 ABILIFY 1 MG/ML SOLUTION H7XA ABILIFY 2 MG TABLET H7XA ABILIFY 5 MG TABLET H7XA ABILIFY 10 MG TABLET H7XA ABILIFY 15 MG TABLET H7XA ABILIFY 20 MG TABLET H7XA ABILIFY 30 MG TABLET H7XA ABILIFY DISCMELT 10 MG TABLET H7XA ABILIFY DISCMELT 15 MG TABLET H7XA ARIPIPRAZOLE 1MG/ML SOLUTION H7XA January 30, 2017 Copyright Health Information Designs, LLC 3

4 Second Generation (Oral/Regular Acting Injectables) Label Name GCN HIC4 ARIPIPRAZOLE 2MG TABLET H7XA ARIPIPRAZOLE 5MG TABLET H7XA ARIPIPRAZOLE 10MG TABLET H7XA ARIPIPRAZOLE 15MG TABLET H7XA ARIPIPRAZOLE 20MG TABLET H7XA ARIPIPRAZOLE 30MG TABLET H7XA ARIPIPRAZOLE ODT 10MG TABLET H7XA ARIPIPRAZOLE ODT 15MG TABLET H7XA CLOZAPINE 12.5MG TABLET H2LS CLOZAPINE 25 MG TABLET H2LS CLOZAPINE 50 MG TABLET H2LS CLOZAPINE 100 MG TABLET H2LS CLOZAPINE 200 MG TABLET H2LS CLOZAPINE ODT 12.5MG TABLET H2LS CLOZAPINE ODT 25MG TABLET H2LS CLOZAPINE ODT 100MG TABLET H2LS CLOZARIL 25 MG TABLET H2LS CLOZARIL 100 MG TABLET H2LS FANAPT 1 MG TABLET H7TK FANAPT 2 MG TABLET H7TK FANAPT 4 MG TABLET H7TK FANAPT 6 MG TABLET H7TK FANAPT 8 MG TABLET H7TK FANAPT 10 MG TABLET H7TK FANAPT 12 MG TABLET H7TK FANAPT TITRATION PACK H7TK FAZACLO 12.5 MG ODT H2LS FAZACLO 25 MG ODT H2LS FAZACLO 100 MG ODT H2LS FAZACLO 150 MG ODT H2LS FAZACLO 200 MG ODT H2LS GEODON 20 MG CAPSULE H2GD GEODON 40 MG CAPSULE H2GD GEODON 60 MG CAPSULE H2GD GEODON 80 MG CAPSULE H2GD GEODON 20 MG VIAL H2GD INVEGA ER 1.5 MG TABLET H7TH January 30, 2017 Copyright Health Information Designs, LLC 4

5 Second Generation (Oral/Regular Acting Injectables) Label Name GCN HIC4 INVEGA ER 3 MG TABLET H7TH INVEGA ER 6 MG TABLET H7TH INVEGA ER 9 MG TABLET H7TH LATUDA 20 MG TABLET H7TL LATUDA 40 MG TABLET H7TL LATUDA 60 MG TABLET H7TL LATUDA 80 MG TABLET H7TL LATUDA 120 MG TABLET H7TL OLANZAPINE 2.5 MG TABLET H7TD OLANZAPINE 5 MG TABLET H7TD OLANZAPINE 7.5 MG TABLET H7TD OLANZAPINE 10 MG TABLET H7TD OLANZAPINE 10 MG VIAL H7TD OLANZAPINE 15 MG TABLET H7TD OLANZAPINE 20MG TABLET H7TD OLANZAPINE ODT 5MG TABLET H7TD OLANZAPINE ODT 10 MG TABLET H7TD OLANZAPINE ODT 15 MG TABLET H7TD OLANZAPINE ODT 20MG TABLET H7TD OLANZAPINE/FLUOXETINE 3-25 MG H7TD/H2JS OLANZAPINE/FLUOXETINE 6-25 MG H7TD/H2JS OLANZAPINE/FLUOXETINE 6-50 MG H7TD/H2JS OLANZAPINE/FLUOXETINE MG H7TD/H2JS OLANZAPINE/FLUOXETINE MG H7TD/H2JS QUETIAPINE 25 MG TABLET H7TF QUETIAPINE 50 MG TABLET H7TF QUETIAPINE 100 MG TABLET H7TF QUETIAPINE 200 MG TABLET H7TF QUETIAPINE 300 MG TABLET H7TF QUETIAPINE 400 MG TABLET H7TF REXULTI 0.25MG TABLET H7XB REXULTI 0.5MG TABLET H7XB REXULTI 1MG TABLET H7XB REXULTI 2MG TABLET H7XB REXULTI 3MG TABLET H7XB REXULTI 4MG TABLET H7XB RISPERDAL 1 MG/ML SOLUTION H7TA January 30, 2017 Copyright Health Information Designs, LLC 5

6 Second Generation (Oral/Regular Acting Injectables) Label Name GCN HIC4 RISPERDAL 0.25 MG TABLET H7TA RISPERDAL 0.5 MG TABLET H7TA RISPERDAL 1 MG TABLET H7TA RISPERDAL 2 MG TABLET H7TA RISPERDAL 3 MG TABLET H7TA RISPERDAL 4 MG TABLET H7TA RISPERDAL M-TAB 0.5 MG ODT H7TA RISPERDAL M-TAB 1 MG ODT H7TA RISPERDAL M-TAB 2 MG ODT H7TA RISPERDAL M-TAB 3 MG ODT H7TA RISPERDAL M-TAB 4 MG ODT H7TA RISPERIDONE 0.25 MG ODT H7TA RISPERIDONE 0.5 MG ODT H7TA RISPERIDONE 1 MG ODT H7TA RISPERIDONE 2 MG ODT H7TA RISPERIDONE 3 MG ODT H7TA RISPERIDONE 4 MG ODT H7TA RISPERIDONE 1 MG/ML SOLUTION H7TA RISPERIDONE 0.25 MG TABLET H7TA RISPERIDONE 0.5 MG TABLET H7TA RISPERIDONE 1 MG TABLET H7TA RISPERIDONE 2 MG TABLET H7TA RISPERIDONE 3 MG TABLET H7TA RISPERIDONE 4 MG TABLET H7TA SAPHRIS 2.5 MG TABLET SUBLINGUAL H7TI SAPHRIS 5 MG TABLET SUBLINGUAL H7TI SAPHRIS 10 MG TAB SUBLINGUAL H7TI SEROQUEL 25 MG TABLET H7TF SEROQUEL 50 MG TABLET H7TF SEROQUEL 100 MG TABLET H7TF SEROQUEL 200 MG TABLET H7TF SEROQUEL 300 MG TABLET H7TF SEROQUEL 400 MG TABLET H7TF SEROQUEL XR 50 MG TABLET H7TF SEROQUEL XR 150 MG TABLET H7TF SEROQUEL XR 200 MG TABLET H7TF SEROQUEL XR 300 MG TABLET H7TF January 30, 2017 Copyright Health Information Designs, LLC 6

7 Second Generation (Oral/Regular Acting Injectables) Label Name GCN HIC4 SEROQUEL XR 400 MG TABLET H7TF SYMBYAX 3-25 MG CAPSULE H7TD/H2JS SYMBYAX 6-25 MG CAPSULE H7TD/H2JS SYMBYAX MG CAPSULE H7TD/H2JS SYMBYAX 6-50 MG CAPSULE H7TD/H2JS SYMBYAX MG CAPSULE H7TD/H2JS VERSACLOZ 50MG/ML SUSPENSION H2LS ZIPRASIDONE 20 MG CAPSULE H7TG ZIPRASIDONE 40 MG CAPSULE H7TG ZIPRASIDONE 60 MG CAPSULE H7TG ZIPRASIDONE 80 MG CAPSULE H7TG ZYPREXA 2.5 MG TABLET H7TD ZYPREXA 5 MG TABLET H7TD ZYPREXA 7.5 MG TABLET H7TD ZYPREXA 10 MG TABLET H7TD ZYPREXA 10 MG VIAL H7TD ZYPREXA 15 MG TABLET H7TD ZYPREXA 20 MG TABLET H7TD ZYPREXA ZYDIS 5 MG TABLET H7TD ZYPREXA ZYDIS 10 MG TABLET H7TD ZYPREXA ZYDIS 15 MG TABLET H7TD ZYPREXA ZYDIS 20 MG TABLET H7TD Second Generation (Long-Acting Injectables) Label Name GCN HIC4 ABILIFY MAINTENA ER 300MG SYR H7XA ABILIFY MAINTENA ER 300MG VL H7XA ABILIFY MAINTENA ER 400MG SYR H7XA ABILIFY MAINTENA ER 400MG VL H7XA ARISTADA ER 441MG/1.6ML SYRINGE H7XA ARISTADA ER 662MG/2.4ML SYRINGE H7XA ARISTADA ER 882MG/3.2ML SYRINGE H7XA INVEGA SUSTENNA 39 MG PREF SYR H7TH INVEGA SUSTENNA 78 MG PREF SYR H7TH INVEGA SUSTENNA 117 MG PREF SYR H7TH INVEGA SUSTENNA 156 MG PREF SYR H7TH INVEGA SUSTENNA 234 MG PREF SYR H7TH January 30, 2017 Copyright Health Information Designs, LLC 7

8 Second Generation (Long-Acting Injectables) Label Name GCN HIC4 INVEGA TRINZA 273MG/0.875ML H7TH INVEGA TRINZA 410MG/1.315ML H7TH INVEGA TRINZA 546MG/1.75ML H7TH INVEGA TRINZA 819MG/2.625ML H7TH RISPERDAL CONSTA 12.5 MG SYR H7TA RISPERDAL CONSTA 25 MG SYR H7TA RISPERDAL CONSTA 37.5 MG SYR H7TA RISPERDAL CONSTA 50 MG SYR H7TA ZYPREXA RELPREVV 210 MG VIAL H7TD ZYPREXA RELPREVV 300 MG VIAL H7TD ZYPREXA RELPREVV 405 MG VIAL H7TD January 30, 2017 Copyright Health Information Designs, LLC 8

9 Clinical Edit Criteria Logic 1. Is the incoming claim for a first generation antipsychotic? [ ] Yes Go to #5 [ ] No Go to #2 2. Is the client less than (<) 3 years of age? [ ] Yes - Deny [ ] No - Go to #3 3. Is the client greater than (>) 5 years of age? [ ] Yes Go to #5 [ ] No Go to #4 4. Is the incoming request for aripiprazole or risperidone? [ ] Yes Go to #5 [ ] No - Deny 5. Does the client have a diagnosis of insomnia in the last 365 days? [ ] Yes Go to #8 [ ] No Go to #6 6. Does the client have a diagnosis of major depressive disorder (MDD) in the last 365 days? [ ] Yes Go to #7 [ ] No Go to #8 7. Does the client have 1 claim for an antidepressant agent in the last 60 days? [ ] Yes Go to #9 [ ] No Go to #8 8. Does the client have a diagnosis included in Table A or B in the last 730 days? [ ] Yes Go to #9 [ ] No Deny 9. Does the client have 2 or more active claims for different antipsychotic agents (HIC4) in the last 180 days (excluding the incoming request)? [ ] Yes Go to #10 [ ] No Approve (365 days) 10. Does the client have 2 or more active claims for different antipsychotic agents (HIC4) in the last 30 days (excluding the incoming request)? [ ] Yes - Deny [ ] No Approve (365 days) January 30, 2017 Copyright Health Information Designs, LLC 9

10 Clinical Edit Criteria Logic Diagram Go to Step 5. Yes Step 1 Is the incoming claim for a 1 st generation antipsychotic? No Deny Request Deny Request Yes Step 2 Is the client < 3 years of age? Yes Step 10 No Step 4 Is the incoming request for aripiprazole or risperidone (excluding long-acting preparations)? No Step 3 No Is the client > 5 years of age? Does the client have 2 or more active claims for different antipsychotic agents in the last 30 days (excluding the incoming request)? Yes No Approve Request (365 days) Yes Yes Step 9 Step 5 Does the client have a diagnosis of insomnia in the last 365 days? Does the client have 2 or more active claims for different antipsychotic agents in the last 180 days (excluding the incoming request)? No Approve Request (365 days) No Yes Yes Step 6 Step 8 Does the client have a diagnosis of major depressive disorder in the last 365 days? No Does the client have a diagnosis found in Table A or B in the last 730 days? No Deny Request Yes No Step 7 Does the client have 1 claim for an antidepressant agent in the last 60 days? Yes Go to Step 9. January 30, 2017 Copyright Health Information Designs, LLC 10

11 Clinical Edit Criteria Supporting Tables ICD-9 Code Step 5 (diagnosis of Insomnia) Look back timeframe: 365 days PERSISTENT DISORDER OF INITIATING OR MAINTAINING SLEEP ORGANIC INSOMNIA, UNSPECIFIED INSOMNIA DUE TO MEDICAL CONDITION CLASSIFIED ELSEWHERE INSOMNIA DUE TO MENTAL DISORDER OTHER ORGANIC INSOMNIA INSOMNIA WITH SLEEP APNEA, UNSPECIFIED INSOMNIA, UNSPECIFIED ICD-10 Code F5101 F5102 F5103 F5104 F5105 F5109 G4700 G4701 G4709 PRIMARY INSOMNIA ADJUSTMENT INSOMNIA PARADOXICAL INSOMNIA PSYCHOPHYSIOLOGIC INSOMNIA INSOMNIA DUE TO OTHER MENTAL DISORDER OTHER INSOMNIA NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION INSOMNIA, UNSPECIFIED INSOMNIA DUE TO MEDICAL CONDITION OTHER INSOMNIA ICD-9 Code Step 6 (diagnosis of Major Depressive Disorder [MDD]) 3004 DYSTHYMIC DISORDER Look back timeframe: 365 days MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, UNSPECIFIED MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, MILD MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, MODERATE January 30, 2017 Copyright Health Information Designs, LLC 11

12 ICD-9 Code Step 6 (diagnosis of Major Depressive Disorder [MDD]) Look back timeframe: 365 days MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, UNSPECIFIED MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, MILD ICD-10 Code F341 F320 MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, MODERATE MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION DYSTHYMIC DISORDER MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD F321 F322 F323 F324 F325 F328 F329 F330 F331 F332 F333 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MODERATE MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, SEVERE WITHOUT PSYCHOTIC FEATURES MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, SEVERE WITH PSYCHOTIC FEATURES MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN PARTIAL REMISSION MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, IN FULL REMISSION OTHER DEPRESSIVE EPISODES OTHER DEPRESSIVE EPISODES MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS January 30, 2017 Copyright Health Information Designs, LLC 12

13 Step 6 (diagnosis of Major Depressive Disorder [MDD]) Look back timeframe: 365 days ICD-9 Code F3340 F3341 F3342 F338 F339 MAJOR DEPRESSIVE DISORDER, RECURRENT, IN REMISSION, UNSPECIFIED MAJOR DEPRESSIVE DISORDER, RECURRENT, IN PARTIAL REMISSION MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION OTHER RECURRENT DEPRESSIVE DISORDERS MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED Step 7 (claim for an antidepressant agent) Look back timeframe: 60 days GCN APLENZIN ER 174MG TABLET APLENZIN ER 348MG TABLET APLENZIN ER 522MG TABLET BRINTELLIX 10MG TABLET BRINTELLIX 20MG TABLET BRINTELLIX 5MG TABLET BRISDELLE 7.5MG CAPSULE BUPROPION ER 100MG TABLET BUPROPION ER 150MG TABLET BUPROPION HCL 100MG TABLET BUPROPION HCL 75MG TABLET BUPROPION SR 150MG TABLET BUPROPION SR 200MG TABLET BUPROPION XL 150MG TABLET BUPROPION XL 300MG TABLET CELEXA 20MG TABLET CITALOPRAM 10MG TABLET CITALOPRAM 10MG/5ML SOLUTION CITALOPRAM 20MG TABLET CITALOPRAM 20MG/10ML SOLUTION CITALOPRAM 40MG TABLET DESVENLAFAXINE ER 100MG TABLET DESVENLAFAXINE ER 100MG TABLET January 30, 2017 Copyright Health Information Designs, LLC 13

14 Step 7 (claim for an antidepressant agent) Look back timeframe: 60 days GCN DESVENLAFAXINE ER 50MG TABLET DESVENLAFAXINE ER 50MG TABLET EFFEXOR XR 150MG CAPSULE EFFEXOR XR 37.5MG CAPSULE EFFEXOR XR 75MG CAPSULE EMSAM 12MG/24HR PATCH EMSAM 6MG/24HR PATCH EMSAM 9MG/24HR PATCH ESCITALOPRAM 10MG TABLET ESCITALOPRAM 20MG TABLET ESCITALOPRAM 5MG TABLET ESCITALOPRAM 5MG/5ML SOLUTION FETZIMA 20-40MG TITRATION PAK FETZIMA ER 120MG CAPSULE FETZIMA ER 20MG CAPSULE FETZIMA ER 40MG CAPSULE FETZIMA ER 80MG CAPSULE FLUOXETINE 10MG CAPSULE FLUOXETINE 10MG TABLET FLUOXETINE 20MG CAPSULE FLUOXETINE 20MG TABLET FLUOXETINE 20MG/5ML SOLUTION FLUOXETINE 40MG CAPSULE FLUOXETINE 60MG TABLET FLUOXETINE DR 90MG CAPSULE FLUVOXAMIINE 25MG TABLET FLUVOXAMINE 100MG TABLET FLUVOXAMINE 50MG TABLET FLUVOXAMINE ER 100MG CAPSULE FLUVOXAMINE ER 150MG CAPSULE FORFIVO XL 450MG TABLET KHEDEZLA ER 100MG TABLET KHEDEZLA ER 50MG TABLET LEXAPRO 10MG TABLET LEXAPRO 20MG TABLET LEXAPRO 5 MG TABLET LEXAPRO 5MG/5ML SOLUTION January 30, 2017 Copyright Health Information Designs, LLC 14

15 Step 7 (claim for an antidepressant agent) Look back timeframe: 60 days GCN MARPLAN 10MG TABLET MIRTAZAPINE 15MG ODT MIRTAZAPINE 15MG TABLET MIRTAZAPINE 30MG ODT MIRTAZAPINE 30MG TABLET MIRTAZAPINE 45MG ODT MIRTAZAPINE 45MG TABLET MIRTAZAPINE 7.5MG TABLET NARDIL 15MG TABLET NEFAZODONE 100MG TABLET NEFAZODONE 150MG TABLET NEFAZODONE 200MG TABLET NEFAZODONE 250MG TABLET NEFAZODONE 50MG TABLET OLEPTRO ER 150MG TABLET OLEPTRO ER 300MG TABLET PARNATE 10MG TABLET PAROXETINE 10MG TABLET PAROXETINE 10MG/5ML SUSPENSION PAROXETINE 20MG TABLET PAROXETINE 30MG TABLET PAROXETINE 40MG TABLET PAROXETINE CR 12.5MG TABLET PAROXETINE CR 25MG TABLET PAROXETINE CR 37.5MG TABLET PAXIL 20MG TABLET PAXIL 30MG TABLET PEXEVA 10MG TABLET PEXEVA 20MG TABLET PEXEVA 30MG TABLET PEXEVA 40MG TABLET PHENELZINE SULFATE 15MG TABLET PRISTIQ ER 100MG TABLET PRISTIQ ER 50MG TABLET PROZAC 10MG PULVULE PROZAC 20MG PULVULE PROZAC 20MG/5ML SOLUTION January 30, 2017 Copyright Health Information Designs, LLC 15

16 Step 7 (claim for an antidepressant agent) Look back timeframe: 60 days GCN REMERON 15MG SOLTAB REMERON 15MG TABLET REMERON 30MG SOLTAB REMERON 30MG TABLET REMERON 45MG SOLTAB REMERON 45MG TABLET SERTRALINE 100MG TABLET SERTRALINE 20MG/ML ORAL CONCENTRATE SERTRALINE 25MG TABLET SERTRALINE 50MG TABLET TRANYLCYPROMINE 10MG TABLET TRAZODONE 100MG TABLET TRAZODONE 100MG TABLET TRAZODONE 150MG TABLET TRAZODONE 150MG TABLET TRAZODONE 300MG TABLET TRAZODONE 50MG TABLET TRAZODONE 50MG TABLET VENLAFAXINE 100MG TABLET VENLAFAXINE 25MG TABLET VENLAFAXINE 37.5MG TABLET VENLAFAXINE 50MG TABLET VENLAFAXINE 75MG TABLET VENLAFAXINE ER 150MG CAPSULE VENLAFAXINE ER 150MG TABLET VENLAFAXINE ER 225MG TABLET VENLAFAXINE ER 37.5MG CAPSULE VENLAFAXINE ER 37.5MG TABLET VENLAFAXINE ER 75MG CAPSULE VENLAFAXINE ER 75MG TABLET VIIBRYD 10MG TABLET VIIBRYD 20MG TABLET VIIBRYD 40MG TABLET VIIBRYD TITRATION PACK WELLBUTRIN 75MG TABLET WELLBUTRIN SR 150MG TABLET ZOLOFT 100MG TABLET January 30, 2017 Copyright Health Information Designs, LLC 16

17 Step 7 (claim for an antidepressant agent) Look back timeframe: 60 days GCN ZOLOFT 25MG TABLET ZOLOFT 50MG TABLET ICD-9 Code Step 8 (Table A) Look back timeframe: 730 days SIMPLE TYPE SCHIZOPHRENIA, UNSPECIFIED SIMPLE TYPE SCHIZOPHRENIA, SUBCHRONIC SIMPLE TYPE SCHIZOPHRENIA, CHRONIC SIMPLE TYPE SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION SIMPLE TYPE SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION SIMPLE TYPE SCHIZOPHRENIA, IN REMISSION DISORGANIZED TYPE SCHIZOPHRENIA, UNSPECIFIED DISORGANIZED TYPE SCHIZOPHRENIA, SUBCHRONIC DISORGANIZED TYPE SCHIZOPHRENIA, CHRONIC DISORGANIZED TYPE SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION DISORGANIZED TYPE SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION DISORGANIZED TYPE SCHIZOPHRENIA, IN REMISSION CATATONIC TYPE SCHIZOPHRENIA, UNSPECIFIED CATATONIC TYPE SCHIZOPHRENIA, SUBCHRONIC CATATONIC TYPE SCHIZOPHRENIA, CHRONIC CATATONIC TYPE SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION CATATONIC TYPE SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION CATATONIC TYPE SCHIZOPHRENIA, IN REMISSION PARANOID TYPE SCHIZOPHRENIA, UNSPECIFIED PARANOID TYPE SCHIZOPHRENIA, SUBCHRONIC PARANOID TYPE SCHIZOPHRENIA, CHRONIC PARANOID TYPE SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION PARANOID TYPE SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION January 30, 2017 Copyright Health Information Designs, LLC 17

18 ICD-9 Code Step 8 (Table A) Look back timeframe: 730 days PARANOID TYPE SCHIZOPHRENIA, IN REMISSION SCHIZOPHRENIFORM DISORDER, UNSPECIFIED SCHIZOPHRENIFORM DISORDER, SUBCHRONIC SCHIZOPHRENIFORM DISORDER, CHRONIC SCHIZOPHRENIFORM DISORDER, SUBCHRONIC WITH ACUTE EXACERBATION SCHIZOPHRENIFORM DISORDER, CHRONIC WITH ACUTE EXACERBATION SCHIZOPHRENIFORM DISORDER, IN REMISSION LATENT SCHIZOPHRENIA, UNSPECIFIED LATENT SCHIZOPHRENIA, SUBCHRONIC LATENT SCHIZOPHRENIA, CHRONIC LATENT SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION LATENT SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION LATENT SCHIZOPHRENIA, IN REMISSION SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, UNSPECIFIED SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, SUBCHRONIC SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, CHRONIC SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, SUBCHRONIC WITH ACUTE EXACERBATION SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, CHRONIC WITH ACUTE EXACERBATION SCHIZOPHRENIC DISORDERS, RESIDUAL TYPE, IN REMISSION SCHIZOAFFECTIVE DISORDER, UNSPECIFIED SCHIZOAFFECTIVE DISORDER, SUBCHRONIC SCHIZOAFFECTIVE DISORDER, CHRONIC SCHIZOAFFECTIVE DISORDER, SUBCHRONIC WITH ACUTE EXACERBATION SCHIZOAFFECTIVE DISORDER, CHRONIC WITH ACUTE EXACERBATION SCHIZOAFFECTIVE DISORDER, IN REMISSION OTHER SPECIFIED TYPES OF SCHIZOPHRENIA, UNSPECIFIED OTHER SPECIFIED TYPES OF SCHIZOPHRENIA, SUBCHRONIC OTHER SPECIFIED TYPES OF SCHIZOPHRENIA, CHRONIC OTHER SPECIFIED TYPES OF SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION OTHER SPECIFIED TYPES OF SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION OTHER SPECIFIED TYPES OF SCHIZOPHRENIA, IN REMISSION January 30, 2017 Copyright Health Information Designs, LLC 18

19 ICD-9 Code Step 8 (Table A) Look back timeframe: 730 days UNSPECIFIED SCHIZOPHRENIA, UNSPECIFIED UNSPECIFIED SCHIZOPHRENIA, SUBCHRONIC UNSPECIFIED SCHIZOPHRENIA, CHRONIC UNSPECIFIED SCHIZOPHRENIA, SUBCHRONIC WITH ACUTE EXACERBATION UNSPECIFIED SCHIZOPHRENIA, CHRONIC WITH ACUTE EXACERBATION UNSPECIFIED SCHIZOPHRENIA, IN REMISSION BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, UNSPECIFIED BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MILD BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, UNSPECIFIED BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MILD BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR January 30, 2017 Copyright Health Information Designs, LLC 19

20 ICD-9 Code Step 8 (Table A) Look back timeframe: 730 days BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED BIPOLAR DISORDER, UNSPECIFIED ATYPICAL MANIC DISORDER OTHER BIPOLAR DISORDER UNSPECIFIED EPISODIC MOOD DISORDER OTHER SPECIFIED EPISODIC MOOD DISORDER AUTISTIC DISORDER, CURRENT OR ACTIVE STATE AUTISTIC DISORDER, RESIDUAL STATE CHILDHOOD DISINTEGRATIVE DISORDER, CURRENT OR ACTIVE STATE CHILDHOOD DISINTEGRATIVE DISORDER, RESIDUAL STATE OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, CURRENT OR ACTIVE STATE OTHER SPECIFIED PERVASIVE DEVELOPMENTAL DISORDERS, RESIDUAL STATE UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, CURRENT OR ACTIVE STATE UNSPECIFIED PERVASIVE DEVELOPMENTAL DISORDER, RESIDUAL STATE TOURETTE S DISORDER ICD-10 Code F200 F201 PARANOID SCHIZOPHRENIA DISORGANIZED SCHIZOPHRENIA January 30, 2017 Copyright Health Information Designs, LLC 20

21 ICD-9 Code F202 F203 F205 F2081 F2089 F209 F21 F22 F23 F24 F250 F251 F258 F259 F28 F29 F3010 F3011 F3012 F3013 F302 F303 F304 F308 F309 F310 F3110 F3111 F3112 F3113 F312 Step 8 (Table A) Look back timeframe: 730 days CATATONIC SCHIZOPHRENIA UNDIFFERENTIATED SCHIZOPHRENIA RESIDUAL SCHIZOPHRENIA SCHIZOPHRENIFORM DISORDER OTHER SCHIZOPHRENIA SCHIZOPHRENIA, UNSPECIFIED SCHIZOTYPAL DISORDER DELUSIONAL DISORDERS BRIEF PSYCHOTIC DISORDER SHARED PSYCHOTIC DISORDER SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE OTHER SCHIZOAFFECTIVE DISORDERS SCHIZOAFFECTIVE DISORDER, UNSPECIFIED OTHER PSYCHOTIC DISORDER NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION MANIC EPISODE WITHOUT PSYCHOTIC SYMPTOMS UNSPECIFIED MANIC EPISODE WITHOUT PSYCHOTIC SYMPTOMS MILD MANIC EPISODE WITHOUT PSYCHOTIC SYMPTOMS MODERATE MANIC EPISODE, SEVERE, WITHOUT PSYCHOTIC SYMPTOMS MANIC EPISODE, SEVERE WITH PSYCHOTIC SYMPTOMS MANIC EPISODE IN PARTIAL REMISSION MANIC EPISODE IN FULL REMISSION OTHER MANIC EPISODES MANIC EPISODE, UNSPECIFIED BIPOLAR DISORDER, CURRENT EPISODE HYPOMANIC BIPOLAR DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC FEATURES UNSPECIFIED BIPOLAR DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC FEATURES MILD BIPOLAR DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC FEATURES MODERATE BIPOLAR DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC FEATURES SEVERE BIPOLAR DISORDER, CURRENT EPISODE MANIC SEVERE WITH PSYCHOTIC FEATURES January 30, 2017 Copyright Health Information Designs, LLC 21

22 ICD-9 Code F3130 F3131 F3132 F314 F315 F3160 F3161 F3162 F3163 F3164 F3170 F3171 F3172 F3173 F3174 F3175 F3176 F3177 F3178 F3181 F3189 F319 F340 F341 F3481 F3489 F349 Step 8 (Table A) Look back timeframe: 730 days BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD OR MODERATE SEVERITY UNSPECIFIED BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MILD BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, SEVERE, WITHOUT PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, SEVERE, WITH PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENT EPISODE MIXED UNSPECIFIED BIPOLAR DISORDER, CURRENT EPISODE MIXED MILD BIPOLAR DISORDER, CURRENT EPISODE MIXED MODERATE BIPOLAR DISORDER, CURRENT EPISODE MIXED SEVERE, WITHOUT PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENT EPISODE MIXED SEVERE, WITH PSYCHOTIC FEATURES BIPOLAR DISORDER, CURRENTLY IN REMISSION MOST RECENT EPISODE UNSPECIFIED BIPOLAR DISORDER, IN PARTIAL REMISSION, MOST RECENT EPISODE HYPOMANIC BIPOLAR DISORDER, IN FULL REMISSION, MOST RECENT EPISODE HYPOMANIC BIPOLAR DISORDER, IN PARTIAL REMISSION, MOST RECENT EPISODE MANIC BIPOLAR DISORDER, IN FULL REMISSION, MOST RECENT EPISODE MANIC BIPOLAR DISORDER, IN PARTIAL REMISSION, MOST RECENT EPISODE DEPRESSED BIPOLAR DISORDER, IN FULL REMISSION, MOST RECENT EPISODE DEPRESSED BIPOLAR DISORDER, IN PARTIAL REMISSION, MOST RECENT EPISODE MIXED BIPOLAR DISORDER, IN FULL REMISSION, MOST RECENT EPISODE MIXED BIPOLAR II DISORDER OTHER BIPOLAR DISORDER BIPOLAR DISORDER, UNSPECIFIED CYCLOTHYMIC DISORDER DYSTHYMIC DISORDER DISRUPTIVE MOOD DYSREGULATION DISORDER OTHER SPECIFIED PERSISTENT MOOD DISORDERS PERSISTENT MOOD [AFFECTIVE] DISORDER, UNSPECIFIED January 30, 2017 Copyright Health Information Designs, LLC 22

23 Step 8 (Table A) Look back timeframe: 730 days ICD-9 Code F39 F840 F842 F843 F845 F848 F849 F952 UNSPECIFIED MOOD [AFFECTIVE] DISORDER AUTISTIC DISORDER RETT'S SYNDROME OTHER CHILDHOOD DISINTEGRATIVE DISORDER ASPERGER'S SYNDROME OTHER PERVASIVE DEVELOPMENTAL DISORDERS PERVASIVE DEVELOPMENTAL DISORDER, UNSPECIFIED TOURETTE S DISORDER Step 8 (Table B) Look back timeframe: 730 days ICD-9 Code 2970 PARANOID STATE, SIMPLE 2971 DELUSIONAL DISORDER 2972 PARAPHRENIA 2973 SHARED PSYCHOTIC DISORDER 2978 OTHER SPECIFIED PARANOID STATES 2979 UNSPECIFIED PARANOID STATE 2989 UNSPECIFIED PSYCHOSIS INTERMITTENT EXPLOSIVE DISORDER CONDUCT DISORDER, CHILDHOOD ONSET CONDUCT DISORDER, ADOLESCENT ONSET CONDUCT DISORDER, ONSET UNSPECIFIED OPPOSITIONAL DEFIANT DISORDER ICD-10 Code F22 F23 F24 F29 F6381 F911 DELUSIONAL DISORDERS BRIEF PSYCHOTIC DISORDER SHARED PSYCHOTIC DISORDER UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION INTERMITTENT EXPLOSIVE DISORDER CONDUCT DISORDER, CHILDHOOD-ONSET TYPE January 30, 2017 Copyright Health Information Designs, LLC 23

24 Step 8 (Table B) Look back timeframe: 730 days ICD-9 Code F912 F913 F919 CONDUCT DISORDER, ADOLESCENT-ONSET TYPE OPPOSITIONAL DEFIANT DISORDER CONDUCT DISORDER, UNSPECIFIED Step 9 (2 active claims for different antipsychotic agents (HIC4) excluding the incoming request) Required quantity: 2 Look back timeframe: 180 days For the list of antipsychotic agents that pertain to this step, see the table in the Drugs Requiring Prior Authorization section. Note: Click the hyperlink to navigate directly to the table. Step 10 (2 active claims for different antipsychotic agents (HIC4) excluding the incoming request) Required quantity: 2 Look back timeframe: 30 days For the list of antipsychotic agents that pertain to this step, see the table in the Drugs Requiring Prior Authorization section. Note: Click the hyperlink to navigate directly to the table. January 30, 2017 Copyright Health Information Designs, LLC 24

25 References 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier / Gold Standard, Inc Available at Accessed on June 30, Micromedex [online database]. Available at Accessed on June 30, ICD-9-CM Diagnosis Codes, Volume Available at Accessed on June 30, ICD-10-CM Diagnosis Codes, Volume Available at Accessed on June 30, ICD-9-CM Diagnosis Codes, Volume Available at Accessed on December 18, ICD-10-CM Diagnosis Codes, Volume Available at Accessed on December 18, Treatment of Patients With Major Depressive Disorder. American Psychiatric Association Practice Guidelines. November Available at 8. Practice Parameter For the Use of Atypical Antipsychotic Medications in Children and Adolescents. American Academy of Child and Adolescent Psychiatry Available at 9. Schutte-Rodin S, Broch L, Buysse D, et al. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. Journal of Clinical Sleep Medicine 2008;4(5): Available at 10.Ramakrishnan K, Scheid DC. Treatment Options for Insomnia. Am Fam Physician Aug 15;76(4): Available at 11.Ramar K, Olson EJ. Management of Common Sleep Disorders. Am Fam Physician Aug 15;88(4): Available at 12.Drugs for Insomnia. Treatment Guidelines from The Medical Letter. July 1, 2012;119:57. January 30, 2017 Copyright Health Information Designs, LLC 25

26 13.Brooks JO, Goldberg JF, Ketter TA, et al. Safety and Tolerability Associated With Second-Generation Antipsychotic Polytherapy in Bipolar Disorder: Findings From the Systematic Treatment Enhancement Program for Bipolar Disorder. J Clin Psychiatry 2011;72(2): January 30, 2017 Copyright Health Information Designs, LLC 26

27 Publication History The Publication History records the publication iterations and revisions to this document. Notes for the most current revision are also provided in the Revision Notes on the first page of this document. Publication Date Notes 06/14/2011 Initial publication and posting to website 10/13/2011 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Criteria Supporting Tables section, revised section to specify the drug names, GCNs, and HICLs pertinent to steps 2 and 3 of the logic diagram 12/31/2012 Added Latuda and amitriptyline/perphenazine to the drug table 03/26/2014 Added additional criteria and expanded Clinical Edit Criteria Supporting Tables 10/30/2014 Revised Step 1 of Clinical Edit Criteria and Logic Diagram Removed Table C from Clinical Edit Supporting Tables 03/20/2015 Added GCNs for Abilify Maintena syringes to the Drugs Requiring Prior Authorization table 04/21/2015 Revised Clinical Edit Criteria and Logic Diagram to reflect duplicate therapy check through HIC4s 10/07/2015 Revised Clinical Edit Criteria and Logic Diagram - updated criteria to reflect when a patient is taking a first generation antipsychotic the logic then goes to Step 5 Updated Criteria Logic Diagram, Step 8 Does the client have a diagnosis found in Table A or B in the last 730 days? 12/18/2015 Added GCNs for Aristada ER injection, Rexulti tablets, Brintellix tablets and Fetzima capsules Updated and verified all ICD-9s and 10s 02/01/2016 Added GCNs for Invega Trinza 02/26/2016 Updated HIC4 for quetiapine containing agents 03/08/2016 Reviewed and updated diagnoses for insomnia 03/23/2016 Added GCN for Saphris 2.5mg tablet 05/18/2016 Added GCN for Zyprexa/Olanzapine 10mg vial January 30, 2017 Copyright Health Information Designs, LLC 27

28 Publication Date Notes 07/19/2016 Added GCNs for Aristada 12/05/2016 Updated criteria logic, page 9. Amended answer for question 7 to If no, go to #8 Updated logic diagram, page 10 01/30/2017 Updated ICD-10s, Table A, page 22 January 30, 2017 Copyright Health Information Designs, LLC 28

Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria

Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Drug/Drug Class Antipsychotics Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior

More information

Antipsychotics Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients

Antipsychotics Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients Antipsychotics Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients Preferred Agents (Oral) a Amitriptyline/Perphenazine (Generic) Aripiprazole Tablet (Generic) b Chlorpromazine

More information

ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR

ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if

More information

Texas Standard Prior Authorization Form Addendum

Texas Standard Prior Authorization Form Addendum Texas Standard Prior Authorization Form Addendum Molina Healthcare of Texas Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA Regulations. Complete / Review

More information

U T I L I Z A T I O N E D I T S

U T I L I Z A T I O N E D I T S I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental

More information

Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children

Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children Judges Reference Table for the Psychotropic Medication Utilization Parameters for Foster Children Stimulants for treatment of ADHD Preschool (Ages 3-5 years) Child (Ages 6-12 years) Adolescent (Ages 13-17

More information

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.

More information

Medications and Children Disorders

Medications and Children Disorders Mental Health Comprehensive Services Providing Family Stability and Developing Life Coping Skills Medications and Children Disorders Psychiatric medications can be an effective part of the treatment for

More information

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid

More information

Antipsychotic Medications Age and Step Therapy

Antipsychotic Medications Age and Step Therapy Market DC *- Florida Healthy Kids Antipsychotic Medications Age and Step Therapy Override(s) Approval Duration Prior Authorization 1 year Quantity Limit *Virginia Medicaid See State Specific Mandates *Indiana

More information

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Pharmacy Medical Necessity Guidelines: Effective: October 1, 2016 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit

More information

HOSPITAL BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) MEASURE SET

HOSPITAL BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) MEASURE SET HOSPITAL BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) MEASURE SET Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: February, 2013 Most recently revised: December 2018 The Psychiatric Measure Set CMS

More information

IMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members

IMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members IMPORTANT NOTICE Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members These changes apply only to members covered under the DC Healthcare Alliance program Alliance

More information

Appendix: Psychotropic Medication Reference Tables

Appendix: Psychotropic Medication Reference Tables Appendix: Psychotropic Medication Reference Tables How to Use these Tables These reference tables are designed to provide clinic staff with specific medication related criteria for the Polypharmacy, Cardiometabolic

More information

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Pharmacy Medical Necessity Guidelines: Effective: April 1, 2018 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit

More information

Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS

Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS Workforce Safety & Insurance Revised Document Date: 07/21/2015 1600 E Century Ave Ste 1 PO Box 5585 Bismarck, ND 58506-5585 701.328.3800 1.800.777.5033 www.workforcesafety.com Pharmacy Benefit Management

More information

Nuplazid (pimavanserin)

Nuplazid (pimavanserin) Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by the Texas Medicaid Vendor Drug Program to ensure appropriate and safe utilization. Additional

More information

Steps for Initiating Electroconvulsive Therapy Treatment

Steps for Initiating Electroconvulsive Therapy Treatment Steps for Initiating Electroconvulsive Therapy Treatment PSYCHIATRISTS CAN REFER PATIENTS FOR ECT TREATMENT AT EL CAMINO HOSPITAL BY CALLING THE ECT NURSE COORDINATOR AT 650-962-5795. Once the referral

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Invega Sustenna, Invega Trinza) Reference Number: CP.PHAR.291 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Medicaid See Important Reminder at the end of this policy

More information

2015 Step Therapy Prior Authorization Medical Necessity Guidelines

2015 Step Therapy Prior Authorization Medical Necessity Guidelines Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154

More information

ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017

ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017 ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG FETZIMA CAPSULE

More information

Step Therapy Group. Atypical Antipsychotic Agents

Step Therapy Group. Atypical Antipsychotic Agents Atypical Antipsychotic Agents Any beneficiary newly enrolled into Community Care, Inc. currently receiving aripiprazole, aripiprazole ODT, risperidone, risperidone ODT, olanzapine, olanzapine ODT, quetiapine,

More information

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES Generic Brand HICL GCN Exception/Other BUPROPION HCL WELLBUTRIN, 01653 WELLBUTRIN SR, WELLBUTRIN XL BUPROPION HBR APLENZIN 17050 16996 26198 CITALOPRAM CELEXA 10321 GPID 16344 HYDROBROMIDE DESVENLAFAXINE

More information

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG NAME. Use Brand Only

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG NAME. Use Brand Only ACAMPROSATE TABLET DELAYED RELEASE ALPHA-TOCOPHEROL CAPSULES ALPRAZOLAM CONCENTRATE 1 MG/ML ALPRAZOLAM ODT TABLET 0.25MG, 0.5MG, 1MG ALPRAZOLAM ODT TABLET 2MG ALPRAZOLAM SR TABLET 24-HOUR ALPRAZOLAM TABLET

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Abilify Maintena, Aristada, Aristada Initio) Reference Number: CP.PHAR.290 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Medicaid Coding Implications Revision Log

More information

Rexulti (brexpiprazole)

Rexulti (brexpiprazole) Market DC Rexulti (brexpiprazole) Override(s) Approval Duration Prior Authorization 1 year Quantity Limit *Indiana see State Specific Mandates below *Maryland see State Specific Mandates below *Virginia

More information

Schedule FDA & literature based indications

Schedule FDA & literature based indications Psychotropic Medication List Recommended dosages are intended to serve only as a guide for children. Recommended doses are literature based. Clinicians should consult package insert of medications for

More information

Guide to Psychiatric Medications for Children and Adolescents

Guide to Psychiatric Medications for Children and Adolescents Guide to Psychiatric Medications for Children and Adolescents by Glenn S. Hirsch, M.D. The following guide includes most of the medications used to treat child and adolescent mental disorders. It lists

More information

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Effective: July. 1, 2016 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy

More information

TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY

TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY TMS - DEPRESSION HISTORY Date: Patient Name: DOB: How did you hear about TMS? What do you know about TMS? Referring Physician? Name of Practice: Name of Inpatient Treatment for Depression: Name of Inpatient

More information

ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018

ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018 ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL FETZIMA

More information

AHCCCS BEHAVIORAL HEALTH DRUG LIST EFFECTIVE OCTOBER 1, 2016

AHCCCS BEHAVIORAL HEALTH DRUG LIST EFFECTIVE OCTOBER 1, 2016 Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date

More information

Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA

Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA Goals of Medications Use least number at lowest dose to get

More information

Dealing with a Mental Health Crisis

Dealing with a Mental Health Crisis Dealing with a Mental Health Crisis Information and Resources for First Responders P... PROFESSIONAL WHAT NAMI DOES NAMI Minnesota is a statewide 501(c)(3) grassroots nonprofit organization dedicated to

More information

MO Medicaid Foster Care Drugs FY10-FY14

MO Medicaid Foster Care Drugs FY10-FY14 MO Medicaid Foster Care Drugs FY10-FY14 Medicaid (MO HealthNet) Cost of Drugs given to Missouri Foster Care Children by combinations of Age, Gender, Drug Class and Fiscal Year [Raw Data Provided by Missouri

More information

Review of Psychotrophic Medications. (An approved North Carolina Division of Health Services Regulation Continuing Education Course)

Review of Psychotrophic Medications. (An approved North Carolina Division of Health Services Regulation Continuing Education Course) Review of Psychotrophic Medications (An approved North Carolina Division of Health Services Regulation Continuing Education Course) Common Psychiatric Disorders *Schizophrenia *Depression *Bipolar Disorder

More information

Kentucky Department for Medicaid Services. Pharmacy and Therapeutics Advisory Committee Recommendations. November 18, 2010 Meeting

Kentucky Department for Medicaid Services. Pharmacy and Therapeutics Advisory Committee Recommendations. November 18, 2010 Meeting Kentucky Department for Medicaid Services Pharmacy and Therapeutics Advisory Committee Recommendations November 18, 2010 Meeting The following chart provides a summary of the recommendations that were

More information

Clinical Policy: Olanzapine Long-Acting Injection (Zyprexa Relprevv) Reference Number: CP.PHAR.292 Effective Date: Last Review Date: 08.

Clinical Policy: Olanzapine Long-Acting Injection (Zyprexa Relprevv) Reference Number: CP.PHAR.292 Effective Date: Last Review Date: 08. Clinical Policy: (Zyprexa Relprevv) Reference Number: CP.PHAR.292 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Medicaid See Important Reminder at the end of this policy for important

More information

Use Brand Only. Preferred Drug Status PRIOR AUTHORIZATION REQUIRED

Use Brand Only. Preferred Drug Status PRIOR AUTHORIZATION REQUIRED Generic Drugs Are Over Brand Drugs Unless Specified As Brand ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE REMERON 30 30 MIRTAZAPINE REMERON SOLTAB 30 30 ISOCARBOXAZID TABLETS

More information

NorthSTAR. Pharmacy Manual

NorthSTAR. Pharmacy Manual NorthSTAR Pharmacy Manual Revised October, 2008 Table of I. Introduction II. III. IV. Antidepressants New Generation Antipsychotic Medications Mood Stabilizers V. ADHD Medications VI. Anxiolytics and Sedative-Hypnotics

More information

Antidepressant Medication Strategies We ve Come a Long Way or Have We? Who Writes Prescriptions for Psychotropic Medications. Biological Psychiatry

Antidepressant Medication Strategies We ve Come a Long Way or Have We? Who Writes Prescriptions for Psychotropic Medications. Biological Psychiatry Antidepressant Medication Strategies We ve Come a Long Way or Have We? Joe Wegmann, PD, LCSW The PharmaTherapist Joe@ThePharmaTherapist.com 504.587.9798 www.pharmatherapist.com Are you receiving our free

More information

PHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES

PHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES PHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES Table of Contents Print TABLE OF CONTENTS Drug Page Number Anafranil... 2 Asendin... 4 Celexa... 4 Cymbalta... 6 Desyrel... 8 Effexor...10 Elavil...14

More information

Commissioner for the Department for Medicaid Services Selections for Preferred Products

Commissioner for the Department for Medicaid Services Selections for Preferred Products Commissioner for the Department for Medicaid Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Commissioner for the Department for

More information

Psychiatric Medication Guide

Psychiatric Medication Guide Psychiatric Medication Guide F O R : N E O N P R I M A R Y H E A L T H C A R E P R O V I D E R S B Y : M I C H E L L E R O M E R O, D O M A Y, 2 0 1 3 Anti-depressants TCA s & MAOI s (Tricyclic Antidepressants

More information

USF Health Psychiatry Clinic. New Patient Questionnaire Adult

USF Health Psychiatry Clinic. New Patient Questionnaire Adult USF Health Psychiatry Clinic New Patient Questionnaire Adult Please mail or fax the completed forms to the address/fax number on the bottom of this page. Completed forms must be received five (5) days

More information

New Patient Questionnaire

New Patient Questionnaire 4 Embarcadero Center, Suite 1400, San Francisco, CA 94111 (415) 926-7774 phone; (415) 591-7760 office@sanfranciscopsych.com New Patient Questionnaire Thank you for trusting San Francisco Psychiatry with

More information

Depression. University of Illinois at Chicago College of Nursing

Depression. University of Illinois at Chicago College of Nursing Depression University of Illinois at Chicago College of Nursing 1 Learning Objectives Upon completion of this session, participants will be better able to: 1. Recognize depression, its symptoms and behaviors

More information

ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY

ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY ANTIDEPRESSANTS Serotonin Selective Reuptake Inhibitors citalopram 10, 20, 40 mg, 10 mg/5cc $ 0.40 No escitalopram 10, 20 mg $ 2.60 Yes fluoxetine 10, 20 mg, 20 mg/5 ml $ 0.40 Yes fluvoxamine 25, 50, 100

More information

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 05/01/2015

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 05/01/2015 Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 05/01/2015 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority

More information

Drug Use Criteria: Atypical Antipsychotics (oral)

Drug Use Criteria: Atypical Antipsychotics (oral) Texas Vendor Drug Program Drug Use Criteria: Atypical Antipsychotics (oral) Publication History 1. Developed: February 1997 2. Revised: September 2017; September 2015; December 2013; February 2012; June

More information

Overview and Update on Current Psychopharmacological Medications, Including New Medications in Clinical Trials

Overview and Update on Current Psychopharmacological Medications, Including New Medications in Clinical Trials SPEAKER NOTES Overview and Update on Current Psychopharmacological Medications, Including New Medications in Clinical Trials Summarized by Thomas T. Thomas New psychotropic medications are coming on the

More information

Psychiatric Illness. In the medical arena psychiatry is a fairly recent field A challenging field Numerous diagnosis

Psychiatric Illness. In the medical arena psychiatry is a fairly recent field A challenging field Numerous diagnosis Psychiatric Illness In the medical arena psychiatry is a fairly recent field A challenging field Numerous diagnosis 12,000,000 children infants through 18 y/o nation wide 5,000,000 suffer severely Serious

More information

Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

Psychotropic Use in the Homeless Population

Psychotropic Use in the Homeless Population Psychotropic Use in the Homeless Population Whitney Ruddock, PharmD Memorial Hospital West Objectives To investigate the correlation between mental illness and homelessness To identify the social, mental,

More information

2015 Update on Psychotropics

2015 Update on Psychotropics 2015 Update on Psychotropics Jeffrey T. Apter, M.D. August 2015 Princeton Medical Institute 256 Bunn Drive, Suite 6, Princeton NJ (609) 921-6050 Learning Objectives Upon completion of this session, participants

More information

Where to from Here? Evidence-Based Strategies for Treatment of Refractory Depression

Where to from Here? Evidence-Based Strategies for Treatment of Refractory Depression Where to from Here? Evidence-Based Strategies for Treatment of Refractory Depression Michael D. Jibson, MD, PhD Professor of Psychiatry University of Michigan Major Depression #1 WHO cause of disability

More information

Texas Prior Authorization Program Clinical Edit Criteria

Texas Prior Authorization Program Clinical Edit Criteria Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization

More information

Step Therapy Requirements. Effective: 03/01/2015

Step Therapy Requirements. Effective: 03/01/2015 Effective: 03/01/2015 Updated 02/2015 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA OXTELLAR XR POTIGA QUDEXY

More information

Prior Authorization. Physician Name: Specialty: NPI Number: Physician Fax: Physician Phone: Physician Address: City, State, Zip:

Prior Authorization. Physician Name: Specialty: NPI Number: Physician Fax: Physician Phone: Physician Address: City, State, Zip: 12/16/2015 Prior Authorization AETA BETTER HEALTH OF TEXAS MEDICAID Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Antipsychotics and stroke risk

Antipsychotics and stroke risk Integrating Sentinel into Routine Regulatory Drug Review: A Snapshot of the First Year Antipsychotics and stroke risk Lockwood G. Taylor, PhD, MPH Division of Epidemiology II Office of Pharmacovigilance

More information

Nebraska Medicaid Criteria. Abilify Maintena

Nebraska Medicaid Criteria. Abilify Maintena Nebraska Medicaid Criteria All initial and renewal authorizations are for 12 months in duration. Abilify Maintena *Criteria for Authorization for Abilify Maintena The individual has a current DSM diagnosis

More information

Antipsychotics. Something Old, Something New, Something Used to Treat the Blues

Antipsychotics. Something Old, Something New, Something Used to Treat the Blues Antipsychotics Something Old, Something New, Something Used to Treat the Blues Objectives To provide an overview of the key differences between first and second generation agents To an overview the newer

More information

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: December 12, 2017

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: December 12, 2017 Pharmacy Medical Necessity Guidelines: Effective: December 12, 2017 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED)

More information

HCA BHS Prescribing Guidelines Committee - Approved Medications 2012

HCA BHS Prescribing Guidelines Committee - Approved Medications 2012 Amitriptyline/Perphenazine Triavil MAJOR TRANQUILIZERS Beneficiaries 10/2, 10/4, 25/2, 25/4, 50/4 Aripiprazole Abilify 2mg, 5mg, 10mg, 15mg, 20mg, 30mg Quantity Limit 31 / mo for Asenapine Saphris 5mg,

More information

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: February 20, 2017

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: February 20, 2017 Pharmacy Medical Necessity Guidelines: Effective: February 20, 2017 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED)

More information

Slide 1. Slide 2. Slide 3. About this module. About this module. Antipsychotics: The Essentials Module 5 A Primer on Selected Antipsychotics

Slide 1. Slide 2. Slide 3. About this module. About this module. Antipsychotics: The Essentials Module 5 A Primer on Selected Antipsychotics Slide 1 Antipsychotics: The Essentials Module 5 A Primer on Selected Antipsychotics Flavio Guzmán, MD Slide 2 About this module 13 antipsychotics will be studied 3 first generation antipsychotics 10 second

More information

Table of substance use disorder diagnoses:

Table of substance use disorder diagnoses: Table of substance use disorder diagnoses: ICD-9 Codes Description 291 Alcohol withdrawal delirium 291.3 Alcohol-induced psychotic disorder with hallucinations 291.4 Idiosyncratic alcohol intoxication

More information

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 01/01/2017

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 01/01/2017 Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 01/01/2017 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Reference Number: AZ.CP.PHAR.10.11.10 Effective Date: 07.16 Last Review Date: 09.12.18 Line of Business: Medicaid Arizona Revision Log See Important Reminder at the end of this policy

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Antipsychotics

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Antipsychotics MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF PHARMACEUTICAL SERVICES I. Requirements for Prior Authorization of Antipsychotics A. Prescriptions That Require Prior Authorization Prescriptions for Antipsychotics

More information

May 22, DAL: DAL SUBJECT: Hot Weather Advisory. Dear Administrator/Operator:

May 22, DAL: DAL SUBJECT: Hot Weather Advisory. Dear Administrator/Operator: May 22, 2013 DAL: DAL 13-11 SUBJECT: Hot Weather Advisory Dear Administrator/Operator: The New York State Department of Health would like to remind you of our expectations regarding the protection of Adult

More information

INPATIENT INCLUDED ICD-10 CODES

INPATIENT INCLUDED ICD-10 CODES INPATIENT INCLUDED ICD-10 CODES MHSUDS IN 18-053 ICD-10 F01.51 Vascular Dementia With Behavioral Disturbance F10.14 Alcohol Abuse With Alcohol-Induced Mood Disorder F10.150 Alcohol Abuse With Alcohol-Induced

More information

ANTICONVULSANTS. Details

ANTICONVULSANTS. Details ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA

More information

Using Drugs to Improve the Behavior of People with Autism: A Skeptical Appraisal. Alan Poling, Ph.D., BCBA-D Western Michigan University

Using Drugs to Improve the Behavior of People with Autism: A Skeptical Appraisal. Alan Poling, Ph.D., BCBA-D Western Michigan University Using Drugs to Improve the Behavior of People with Autism: A Skeptical Appraisal Alan Poling, Ph.D., BCBA-D Western Michigan University In a 2010 study of 60,641 children Mandell et al. found that: 56%

More information

All formulary medications available in generic form are supplied in generic form. Requests for brand name preparations must get prior authorization.

All formulary medications available in generic form are supplied in generic form. Requests for brand name preparations must get prior authorization. Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 10/01/2018 About the Behavioral Health Drug List The Mercy Care behavioral health drug list includes all of the behavioral health

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.

More information

Literature Scan: Parenteral Antipsychotics

Literature Scan: Parenteral Antipsychotics Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017 VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 01/01/2017 Updated 12/23/2016 ANTICONVULSANTS Aptiom 200 mg tablet Potiga 200 mg tablet Aptiom 400 mg tablet Potiga 300 mg tablet Aptiom

More information

Study Guidelines for Quiz #1

Study Guidelines for Quiz #1 Annex to Section J Page 1 Study Guidelines for Quiz #1 Theory and Principles of Psychopharmacology, Classifications and Neurotransmitters, Anxiolytics/Antianxiety/Minor Tranquilizers, Stimulants, Nursing

More information

Step Therapy Requirements

Step Therapy Requirements Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet

More information

Office Practice Coding Assistance - Overview

Office Practice Coding Assistance - Overview Office Practice Coding Assistance - Overview Three office coding assistance resources are provided in the STABLE Resource Toolkit. Depression & Bipolar Coding Reference: n Provides ICD9CM and DSM-IV-TR

More information

Happy Daisy Ltd. New Client intake Form. What are the issues for which you are seeking care?

Happy Daisy Ltd. New Client intake Form. What are the issues for which you are seeking care? Happy Daisy Ltd. New Client intake Form Name Date Preferred name Pronouns Referred by Date of birth Age Race What are the issues for which you are seeking care? 1. 2. 3. Please check of any of the symptoms

More information

Adult Depression - Clinical Practice Guideline

Adult Depression - Clinical Practice Guideline 1 Adult Depression - Clinical Practice Guideline 05/2018 Diagnosis and Screening Diagnostic criteria o Please refer to Attachment A Screening o The United States Preventative Services Task Force (USPSTF)

More information

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 4/01/2018

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 4/01/2018 Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 4/01/2018 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority

More information

90 dosage units per 90 days OR. Extended-release Formulations Ultram ER 90 dosage units per 90 days OR

90 dosage units per 90 days OR. Extended-release Formulations Ultram ER 90 dosage units per 90 days OR Pre - PA Allowance 12 years of age or older Quantity Immediate-release Formulation Ultracet 720 dosage units per 90 days OR Ultram 720 dosage units per 90 days Extended-release Formulations Ultram ER 90

More information

Debra Brown, PharmD, FASCP Pharmaceutical Consultant II Specialist. HMS Training Webinar January 27, 2017

Debra Brown, PharmD, FASCP Pharmaceutical Consultant II Specialist. HMS Training Webinar January 27, 2017 Debra Brown, PharmD, FASCP Pharmaceutical Consultant II Specialist HMS Training Webinar January 27, 2017 1 Describe nationwide prevalence and types of elderly dementia + define BPSD Define psychotropic

More information

Mental Health Medications. National Institute of Mental Health. U.S. Department of HealtH and HUman ServiceS National Institutes of Health

Mental Health Medications. National Institute of Mental Health. U.S. Department of HealtH and HUman ServiceS National Institutes of Health Mental Health Medications National Institute of Mental Health U.S. Department of HealtH and HUman ServiceS National Institutes of Health Contents Mental Health Medications...1 What are psychiatric medications?...1

More information

ANTICONVULSANTS. Details

ANTICONVULSANTS. Details ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension

More information

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG CLASS

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG CLASS ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE ODT TABLETS 15 MG REMERON SOL 90 30 MIRTAZAPINE ODT TABLETS 30 MG REMERON SOL 45 30 MIRTAZAPINE ODT TABLETS 45 MG REMERON SOL 30

More information

MORPHINE IR DRUG CLASS Morphine IR, Dilaudid IR (hydromorphone), Opana IR (oxymorphone)

MORPHINE IR DRUG CLASS Morphine IR, Dilaudid IR (hydromorphone), Opana IR (oxymorphone) Pre - PA Allowance Tablets & Suppositories Morphine sulfate tablets Morphine sulfate suppositories Oxymorphone tablets Hydromorphone tablets Hydromorphone suppositories 360 tablets per 90 days OR 360 suppositories

More information

Treat mood, cognition, and behavioral disturbances associated with psychological disorders. Most are not used recreationally or abused

Treat mood, cognition, and behavioral disturbances associated with psychological disorders. Most are not used recreationally or abused Psychiatric Drugs Psychiatric Drugs Treat mood, cognition, and behavioral disturbances associated with psychological disorders Psychotropic in nature Most are not used recreationally or abused Benzodiazepines

More information

Step Therapy Requirements. Effective: 1/1/2019

Step Therapy Requirements. Effective: 1/1/2019 Effective: 1/1/2019 Updated 1/2019 AMANTADINE ER Sharp Health Plan (HMO) OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE

More information

$"% & '( ) " * +, !"##!""$ !*$-!+*" % $&

$% & '( )  * +, !##!$ !*$-!+* % $& ! """# # $"% & '( ')&# '( ) " * +, '( )(*!*$-!+*"!"##!""$ % $& &. / 011 12 ' 32 3 456 3. 3 0 11 32! 71 829:1 1' 3,3 12/ 2 31:181' 337)1 / 111 3 : 39.21)2 231 1 1 13' 223 333 23) 3;3 2 1 1' 11 3 31 333

More information

Sitagliptin (Januvia)

Sitagliptin (Januvia) Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document 25mg Drugs requiring prior authorization: the list of drugs requiring prior

More information

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL* Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA DRUG CLASS PRODUCTS) BRAND NAME (BRAND ONLY) (generic) STEP THERAPY CRITERIA ATYPICAL ANTIPSYCHOTICS (BRAND ONLY ABILIFY (AL TABLET & AL SOLUTION ONLY) (aripiprazole) FANAPT (BRAND ONLY) (iloperidone)

More information

CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.

CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication. ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE

More information