Texas Prior Authorization Program Clinical Criteria

Size: px
Start display at page:

Download "Texas Prior Authorization Program Clinical Criteria"

Transcription

1 Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Ketorolac Clinical Criteria Information Included in this Document Ketorolac Oral Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical 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 criteria Ketorolac Injectable/Nasal Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical 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 criteria te: Click the hyperlink to navigate directly to that section. August 11, 2017 Copyright 2017 Health Information Designs, LLC 1

2 Ketorolac Revision tes Annual review by staff Updated Table 3, pages Updated Table 4, pages Updated criteria logic and diagram to include age checks, pages Updated references, page 26 August 11, 2017 Copyright 2017 Health Information Designs, LLC 2

3 Ketorolac Oral Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization KETOROLAC 10 MG TABLET August 11, 2017 Copyright 2017 Health Information Designs, LLC 3

4 Ketorolac Oral Clinical Criteria Logic 1. Is the client greater than or equal to ( ) 17 years of age? [ ] (Go to #2) [ ] (Deny) 2. Does the client have a diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder in the last 730 days? [ ] (Deny) [ ] (Go to #3) 3. Does the client have a history of an aspirin or NSAID agent in the last 30 days? [ ] (Deny) [ ] (Go to #4) 4. Does the client have a history of a warfarin, heparin, low-molecular-weight heparin (LMWH), or other antihemophilic agent in the last 60 days? [ ] (Deny) [ ] (Go to #5) 5. Has the client received less than or equal to ( ) 5 days total supply of ketorolac therapy in the past 30 days? [ ] (Go to #6) [ ] (Deny) 6. Is the requested dose less than or equal to ( ) 40 mg per day? [ ] (Approve 1 day) [ ] (Deny) August 11, 2017 Copyright 2017 Health Information Designs, LLC 4

5 Ketorolac Oral Clinical Criteria Logic Diagram Step 1 Is the client 17 years of age? Step 2 Does the client have a diagnosis of PUD, GI bleed, cerebrovascular bleeding, ARF or coagulation disorder in the last 730 days? Deny Request Deny Request Step 3 Does the client have a history of an aspirin or NSAID agent in the last 30 days? Deny Request Step 4 Does the client have a history of a warfarin, heparin, LMWH or other antihemophilic agent in the last 60 days? Deny Request Step 5 Has the client received 5 days total supply of ketorolac therapy in the last 30 days? Deny Request Step 6 Is the requested dose 40mg per day? Deny Request Approve Request (1 day) August 11, 2017 Copyright 2017 Health Information Designs, LLC 5

6 Ketorolac Oral Clinical Criteria Supporting Tables Step 2 (diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder) ICD-9 Code Required diagnosis: 1 Look back timeframe: 730 days PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses Description 2860 CONG FACTOR VIII DISORDER 2861 CONG FACTOR IX DISORDER 2862 CONG FACTOR XI DISORDER 2863 CONG DEF CLOT FACTOR NEC 2864 VON WILLEBRAND'S DISEASE 2865 HERMORRNAGIC DISODER DUE TO INTRINSIC CIRCULATING ANTICOAGULANTS 2866 DEFIBRINATION SYNDROME 2867 ACQ COAGUL FACTOR DEFIC 2869 COAGULAT DEFECT NEC/NOS HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 430 SUBARACHNOID HEMORRHAGE 431 INTRACEREBRAL HEMORRHAGE 432 OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE AC STOMACH ULCER W HEM AC STOMAC ULC W HEM-OBST AC STOMACH ULCER W PERF AC STOM ULC W PERF-OBST AC STOMAC ULC W HEM/PERF AC STOM ULC HEM/PERF-OBS ACUTE STOMACH ULCER NOS AC STOMACH ULC NOS-OBSTR August 11, 2017 Copyright 2017 Health Information Designs, LLC 6

7 Step 2 (diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder) Required diagnosis: 1 Look back timeframe: 730 days PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses CHR STOMACH ULC W HEM CHR STOM ULC W HEM-OBSTR CHR STOMACH ULCER W PERF CHR STOM ULC W PERF-OBST CHR STOMACH ULC HEM/PERF CHR STOM ULC HEM/PERF-OB CHR STOMACH ULCER NOS CHR STOMACH ULC NOS-OBST STOMACH ULCER NOS STOMACH ULCER NOS-OBSTR AC DUODENAL ULCER W HEM AC DUODEN ULC W HEM-OBST AC DUODENAL ULCER W PERF AC DUODEN ULC PERF-OBSTR AC DUODEN ULC W HEM/PERF AC DUOD ULC HEM/PERF-OBS ACUTE DUODENAL ULCER NOS AC DUODENAL ULC NOS-OBST CHR DUODEN ULCER W HEM CHR DUODEN ULC HEM-OBSTR CHR DUODEN ULCER W PERF CHR DUODEN ULC PERF-OBST CHR DUODEN ULC HEM/PERF CHR DUOD ULC HEM/PERF-OB CHR DUODENAL ULCER NOS CHR DUODEN ULC NOS-OBSTR DUODENAL ULCER NOS DUODENAL ULCER NOS-OBSTR AC PEPTIC ULCER W HEMORR AC PEPTIC ULC W HEM-OBST AC PEPTIC ULCER W PERFOR AC PEPTIC ULC W PERF-OBS AC PEPTIC ULC W HEM/PERF AC PEPT ULC HEM/PERF-OBS ACUTE PEPTIC ULCER NOS August 11, 2017 Copyright 2017 Health Information Designs, LLC 7

8 Step 2 (diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder) Required diagnosis: 1 Look back timeframe: 730 days PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses AC PEPTIC ULCER NOS-OBST CHR PEPTIC ULCER W HEM CHR PEPTIC ULC W HEM-OBS CHR PEPTIC ULCER W PERF CHR PEPTIC ULC PERF-OBST CHR PEPT ULC W HEM/PERF CHR PEPT ULC HEM/PERF-OB CHRONIC PEPTIC ULCER NOS CHR PEPTIC ULCER NOS-OBS PEPTIC ULCER NOS PEPTIC ULCER NOS-OBSTRUC 5804 AC RAPIDLY PROGR NEPHRIT 5824 CHR RAPID PROGR NEPHRIT 5834 RAPIDLY PROG NEPHRIT NOS 5854 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED. 587 RENAL SCLEROSIS NOS V561 V562 V5631 V5632 ICD-10 Code D65 D66 D67 D680 D681 D682 D6832 D684 D688 FITTING AND ADJUSTMENT OF EXTRACORPOREAL DIALYSIS CATHETER FITTING AND ADJUSTMENT OF PERITONEAL DIALYSIS CATHETER ENCOUNTER FOR ADEQUACY TESTING FOR HEMODIALYSIS ENCOUNTER FOR ADEQUACY TESTING FOR PERITONEAL DIALYSIS Description DISSEMINATED INTRAVASCULAR COAGULATION [DEFIBRINATION SYNDROME] HEREDITARY FACTOR VIII DEFICIENCY HEREDITARY FACTOR IX DEFICIENCY VON WILLEBRAND'S DISEASE HEREDITARY FACTOR XI DEFICIENCY HEREDITARY DEFICIENCY OF OTHER CLOTTING FACTORS HEMORRHAGIC DISORDER DUE TO EXTRINSIC CIRCULATING ANTICOAGULANTS ACQUIRED COAGULATION FACTOR DEFICIENCY OTHER SPECIFIED COAGULATION DEFECTS August 11, 2017 Copyright 2017 Health Information Designs, LLC 8

9 Step 2 (diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder) Required diagnosis: 1 Look back timeframe: 730 days PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses D689 I120 I129 I6000 I6001 I6002 I6010 I6011 I6012 I602 I6030 I6031 I6032 I604 I6050 I6051 I6052 I606 I607 I608 I609 K250 K251 COAGULATION DEFECT, UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM UNSPECIFIED CAROTID SIPHON AND BIFURCATION NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM RIGHT CAROTID SIPHON AND BIFURCATION NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM LEFT CAROTID SIPHON AND BIFURCATION NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM UNSPECIFIED MIDDLE CEREBRAL ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM RIGHT MIDDLE CEREBRAL ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM LEFT MIDDLE CEREBRAL ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM ANTERIOR COMMUNICATING ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM UNSPECIFIED POSTERIOR COMMUNICATING ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM RIGHT POSTERIOR COMMUNICATING ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM LEFT POSTERIOR COMMUNICATING ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM BASILAR ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM UNSPECIFIED VERTEBRAL ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM RIGHT VERTEBRAL ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM LEFT VERTEBRAL ARTERY NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM OTHER INTRACRANIAL ARTERIES NONTRAUMATIC SUBARACHNOID HEMORRHAGE FROM UNSPECIFIED INTRACRANIAL ARTERY OTHER NONTRAUMATIC SUBARACHNOID HEMORRHAGE NONTRAUMATIC SUBARACHNOID HEMORRHAGE, UNSPECIFIED ACUTE GASTRIC ULCER WITH HEMORRHAGE ACUTE GASTRIC ULCER WITH PERFORATION August 11, 2017 Copyright 2017 Health Information Designs, LLC 9

10 Step 2 (diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder) Required diagnosis: 1 Look back timeframe: 730 days PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses K252 K253 K254 K255 K256 K257 K259 K260 K261 K262 K263 K264 K265 K266 K267 K269 K270 K271 K272 K273 K274 K275 K276 K277 K279 N010 N011 ACUTE GASTRIC ULCER WITH BOTH HEMORRHAGE AND PERFORATION ACUTE GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH PERFORATION CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH BOTH HEMORRHAGE AND PERFORATION CHRONIC GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION GASTRIC ULCER, UNSPECIFIED AS ACUTE OR CHRONIC, WITHOUT HEMORRHAGE OR PERFORATION ACUTE DUODENAL ULCER WITH HEMORRHAGE ACUTE DUODENAL ULCER WITH PERFORATION ACUTE DUODENAL ULCER WITH BOTH HEMORRHAGE AND PERFORATION ACUTE DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH HEMORRHAGE CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH PERFORATION CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH BOTH HEMORRHAGE AND PERFORATION CHRONIC DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION DUODENAL ULCER, UNSPECIFIED AS ACUTE OR CHRONIC, WITHOUT HEMORRHAGE OR PERFORATION ACUTE PEPTIC ULCER, SITE UNSPECIFIED, WITH HEMORRHAGE ACUTE PEPTIC ULCER, SITE UNSPECIFIED, WITH PERFORATION ACUTE PEPTIC ULCER, SITE UNSPECIFIED, WITH BOTH HEMORRHAGE AND PERFORATION ACUTE PEPTIC ULCER, SITE UNSPECIFIED, WITHOUT HEMORRHAGE OR PERFORATION CHRONIC OR UNSPECIFIED PEPTIC ULCER, SITE UNSPECIFIED, WITH HEMORRHAGE CHRONIC OR UNSPECIFIED PEPTIC ULCER, SITE UNSPECIFIED, WITH PERFORATION CHRONIC OR UNSPECIFIED PEPTIC ULCER, SITE UNSPECIFIED, WITH BOTH HEMORRHAGE AND PERFORATION CHRONIC PEPTIC ULCER, SITE UNSPECIFIED, WITHOUT HEMORRHAGE OR PERFORATION PEPTIC ULCER, SITE UNSPECIFIED, UNSPECIFIED AS ACUTE OR CHRONIC, WITHOUT HEMORRHAGE OR PERFORATION RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS August 11, 2017 Copyright 2017 Health Information Designs, LLC 10

11 N012 N013 N014 N015 N016 N017 N018 N019 N038 N059 N184 Step 2 (diagnosis of peptic ulcer disease (PUD), GI bleed, cerebrovascular bleeding, advanced renal failure (ARF), or coagulation disorder) Required diagnosis: 1 Look back timeframe: 730 days PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH DENSE DEPOSIT DISEASE RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES CHRONIC NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES UNSPECIFIED NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES CHRONIC KIDNEY DISEASE, STAGE 4 (SEVERE) N185 CHRONIC KIDNEY DISEASE, STAGE 5 N186 N189 N261 N269 Z4901 Z4902 Z4931 Z4932 END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED ATROPHY OF KIDNEY (TERMINAL) RENAL SCLEROSIS, UNSPECIFIED ENCOUNTER FOR FITTING AND ADJUSTMENT OF EXTRACORPOREAL DIALYSIS CATHETER ENCOUNTER FOR FITTING AND ADJUSTMENT OF PERITONEAL DIALYSIS CATHETER ENCOUNTER FOR ADEQUACY TESTING FOR HEMODIALYSIS ENCOUNTER FOR ADEQUACY TESTING FOR PERITONEAL DIALYSIS Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents ADD STREN PAIN REL TABLET August 11, 2017 Copyright 2017 Health Information Designs, LLC 11

12 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents AGGRENOX CAPSULE SA 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 ASCOMP WITH CODEINE CAPSULE ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN ADULT 81 MG CHEW TAB ASPIRIN 325 MG TABLET ASPIRIN COATED 325 MG TABLET ASPIRIN EC 81 MG TABLET ASPIRIN EC 325 MG TABLET ASPIR-LOW EC 81 MG TABLET BUTALBITAL COMP-CODEINE #3 CAP BUTALBITAL COMPOUND CAPSULE BUTALBITAL COMPOUND TABLET BUTALBITAL-ASA-CAFFEINE CAP BUTALBITAL-ASA-CAFFEINE TABLET CARISOPRODL-ASPIRIN MG CARISOPRODOL COMPOUND TAB CARISOPRODOL CPD-CODEINE TAB CATAFLAM 50 MG TABLET CELEBREX 50 MG CAPSULE CELEBREX 100 MG CAPSULE CELEBREX 200 MG CAPSULE CELEBREX 400 MG CAPSULE CHILD ASPIRIN 81 MG CHEW TAB CHILD IBUPROFEN 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML CHILDREN'S MEDI-PROFEN SUSP CLINORIL 200 MG TABLET DAYPRO 600 MG CAPLET DICLOFENAC POT 50 MG TABLET August 11, 2017 Copyright 2017 Health Information Designs, LLC 12

13 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 DUEXIS MG TABLET EFFERVESCENT PAIN RELIEF TAB EFFERVESCENT PAIN RELIEF TB ENDODAN MG TABLET 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 FIORINAL MG CAPSULE FIORINAL-COD CAP FLECTOR 1.3% PATCH FLURBIPROFEN 50 MG TABLET FLURBIPROFEN 100 MG TABLET HEADACHE PAIN RELIEF 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 IBUPROFEN 400 MG TABLET August 11, 2017 Copyright 2017 Health Information Designs, LLC 13

14 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 50 MG/1.25 ML INFANTS IBU-DROPS SUSPENSION KETOPROFEN 50 MG CAPSULE KETOPROFEN 75 MG CAPSULE KETOPROFEN ER 200 MG CAPSULE LITE COAT ASPIRIN 325 MG TAB MECLOFENAMATE 50 MG CAPSULE MECLOFENAMATE 100 MG CAPSULE MEDI-PROFEN 200 MG CAPLET MEDI-PROFEN 200 MG TABLET MEFENAMIC ACID 250 MG CAPSULE MELOXICAM 7.5 MG/5 ML SUSP MELOXICAM 7.5 MG TABLET MELOXICAM 15 MG TABLET MIGRAINE FORMULA CAPLET MOBIC 7.5 MG TABLET MOBIC 15 MG TABLET 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 August 11, 2017 Copyright 2017 Health Information Designs, LLC 14

15 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN 250 MG TABLET 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 275 MG TAB NAPROXEN SODIUM 550 MG TAB ORPHENADRINE COMP FORTE TAB ORPHENADRINE COMP TABLET OXAPROZIN 600 MG TABLET OXYCODONE-ASA TAB OXYCODONE-ASPIRIN MG OXYCODONE-IBUPROFEN TAB PENNSAID 1.5% SOLUTION PERCODAN TABLET PIROXICAM 10 MG CAPSULE PIROXICAM 20 MG CAPSULE PONSTEL 250 MG KAPSEALS QC ASPIRIN 325 MG TABLET QC ASPIRIN EC 325 MG TABLET QC CHILD ASPIRIN 81 MG CHW TAB QC HEADACHE RELIEF TABLET QC IBUPROFEN 200 MG CAPLET QC IBUPROFEN 200 MG SOFTGEL QC IBUPROFEN 200 MG TABLET QC LO-DOSE ASPIRIN EC 81 MG TB QC NAPROXEN SOD 220 MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET SM ADDED STRENGTH HEADACHE TAB August 11, 2017 Copyright 2017 Health Information Designs, LLC 15

16 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents SM ASPIRIN 325 MG TABLET SM ASPIRIN EC 81 MG TABLET SM CHILD ASPIRIN 81 MG CHW TAB SM IBUPROFEN 200 MG CAPLET 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 VIMOVO MG TABLET VIMOVO MG TABLET VOLTAREN 1% GEL VOLTAREN-XR 100 MG TABLET ZIPSOR 25 MG CAPSULE ZORPRIN CR 800 MG TABLET Step 4 (history of warfarin, heparin, low-molecular-weight heparin (LMWH) or other antihemophilic drug) Look back timeframe: 60 days Warfarin, Heparin, LWMH, and Other Antihemophilic Agents ADVATE UNITS VIAL ADVATE UNITS VIAL ADVATE 801-1,200 UNITS VIAL ADVATE 1,201-1,800 UNITS VIAL ADVATE 1,801-2,400 UNITS VIAL ADVATE 2,400-3,600 UNITS VIAL ALPHANATE UNIT VIAL ALPHANATE UNIT VIAL August 11, 2017 Copyright 2017 Health Information Designs, LLC 16

17 Step 4 (history of warfarin, heparin, low-molecular-weight heparin (LMWH) or other antihemophilic drug) Look back timeframe: 60 days Warfarin, Heparin, LWMH, and Other Antihemophilic Agents ALPHANATE 1, UNIT VIAL ALPHANATE 1, UNIT VIAL ALPHANINE SD 500 UNITS VIAL ALPHANINE SD 1,000 UNITS VIAL BEBULIN 200-1,200 UNITS VIAL BENEFIX 250 UNIT KIT BENEFIX 500 UNIT KIT BENEFIX 1,000 UNIT KIT BENEFIX 2,000 UNIT KIT BENEFIX 250 UNIT VIAL BENEFIX 500 UNIT VIAL BENEFIX 1,000 UNIT VIAL 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 6 MG TABLET COUMADIN 7.5 MG TABLET COUMADIN 10 MG TABLET COUMADIN 5 MG VIAL ENOXAPARIN 30 MG/0.3 ML SYR ENOXAPARIN 40 MG/0.4 ML SYR ENOXAPARIN 60 MG/0.6 ML SYR ENOXAPARIN 80 MG/0.8 ML SYR ENOXAPARIN 100 MG/ML SYR ENOXAPARIN 120 MG/0.8 ML SYR ENOXAPARIN 150 MG/ML SYR FEIBA VH IMMUNO UNITS FEIBA VH IMMUNO 651-1,200 UNIT FEIBA VH IMMU 1,750-3,250 UNIT FEIBA NF UNIT VIAL August 11, 2017 Copyright 2017 Health Information Designs, LLC 17

18 Step 4 (history of warfarin, heparin, low-molecular-weight heparin (LMWH) or other antihemophilic drug) Look back timeframe: 60 days Warfarin, Heparin, LWMH, and Other Antihemophilic Agents FEIBA NF 651-1,200 UNIT VIAL FEIBA NF 1,750-3,250 UNIT VIAL FRAGMIN 2,500 UNITS SYRINGE FRAGMIN 5,000 UNITS SYRINGE FRAGMIN 7,500 UNITS SYRINGE FRAGMIN 10,000 UNITS SYRINGE FRAGMIN 12,500 UNITS SYRINGE FRAGMIN 15,000 UNITS SYRINGE FRAGMIN 18,000 UNITS SYRINGE FRAGMIN 25,000 UNITS/ML VIAL HELIXATE FS 2,000 UNIT VIAL HELIXATE FS 250 UNIT VIAL HELIXATE FS 500 UNIT VIAL HEMOFIL M UNITS VIAL HEMOFIL M UNITS VIAL HEPARIN LOCK 100 UNITS/ML VIAL HEPARIN SOD 1,000 UNIT/ML VIAL HEPARIN SOD 1,000 UNIT/ML VIAL HEPARIN SOD 5,000 UNIT/ML VIAL HEPARIN SOD 10,000 UNIT/ML VL HEPARIN SOD 20,000 UNIT/ML VL HEPARIN-D5W 25,000 UNIT/500 ML HEPARIN-NS 1,000 UNIT/500 ML HUMATE-P 600 UNIT VWF:RCO HUMATE-P 1,200 UNIT VWF:RCO HUMATE-P 2,400 UNIT VWF:RCO 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 August 11, 2017 Copyright 2017 Health Information Designs, LLC 18

19 Step 4 (history of warfarin, heparin, low-molecular-weight heparin (LMWH) or other antihemophilic drug) Look back timeframe: 60 days Warfarin, Heparin, LWMH, and Other Antihemophilic Agents JANTOVEN 7.5 MG TABLET JANTOVEN 10 MG TABLET KOATE-DVI 250 UNIT KIT KOATE-DVI 500 UNITS KIT KOATE-DVI 1,000 UNITS KIT KOGENATE FS 250 UNIT VIAL KOGENATE FS 500 UNIT VIAL KOGENATE FS 2,000 UNIT VIAL LOVENOX 30 MG PREFILLED SYRN LOVENOX 40 MG PREFILLED SYRN LOVENOX 60 MG PREFILLED SYRN LOVENOX 80 MG PREFILLED SYRN LOVENOX 100 MG PREFILLED SYR LOVENOX 120 MG PREFILLED SYR LOVENOX 150 MG PREFILLED SYR LOVENOX 300 MG/3 ML VIAL MONOCLATE-P 250 UNIT KIT MONOCLATE-P 1,000 UNITS KIT MONOCLATE-P 1,500 UNITS KIT MONOCLATE-P 500AHFU KIT NOVOSEVEN RT 1,000 MCG VIAL NOVOSEVEN RT 2,000 MCG VIAL NOVOSEVEN RT 5,000 MCG VIAL PROFILNINE SD 500 UNITS VIAL RECOMBINATE UNIT VIAL RECOMBINATE UNIT VIAL RECOMBINATE 1,801-2,400 UNIT V 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 WARFARIN SODIUM 5 MG TABLET August 11, 2017 Copyright 2017 Health Information Designs, LLC 19

20 Step 4 (history of warfarin, heparin, low-molecular-weight heparin (LMWH) or other antihemophilic drug) Look back timeframe: 60 days Warfarin, Heparin, LWMH, and Other Antihemophilic Agents WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM 10 MG TABLET XYNTHA 250 UNIT KIT XYNTHA 500 UNIT KIT XYNTHA 1,000 UNIT KIT XYNTHA 2,000 UNIT KIT Step 5 (received less than or equal to 5 days total supply of ketorolac therapy) Look back timeframe: 30 days Ketorolac Therapies KETOROLAC 10 MG TABLET KETOROLAC 15 MG/ML VIAL KETOROLAC 30 MG/ML VIAL KETOROLAC 60 MG/2 ML VIAL SPRIX MG NASAL SPRAY August 11, 2017 Copyright 2017 Health Information Designs, LLC 20

21 Ketorolac, Injectable/Nasal Ketorolac Injectable/Nasal Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization KETOROLAC 15 MG/ML VIAL KETOROLAC 30 MG/ML VIAL KETOROLAC 60 MG/ML VIAL SPRIX MG NASAL SPRAY August 11, 2017 Copyright 2017 Health Information Designs, LLC 21

22 Ketorolac, Injectable/Nasal Ketorolac Injectable/Nasal Clinical Criteria Logic 1. Is the request for injectable ketorolac? [ ] (Go to #2) [ ] (Go to #3) 2. Is the client greater than or equal to ( ) 2 years of age? [ ] (Go to #5) [ ] (Deny) 3. Is the request for nasal ketorolac? [ ] (Go to #4) [ ] (Deny) 4. Is the client greater than or equal to ( ) 18 years of age? [ ] (Go to #5) [ ] (Deny) 5. Does the client have a diagnosis of peptic ulcer disease (PUD), GI bleed, advanced renal failure (ARF), or coagulation disorder in the last 730 days? [ ] (Deny) [ ] (Go to #6) 6. Does the client have a history of an aspirin or NSAID agent in the last 30 days? [ ] (Deny) [ ] (Go to #7) 7. Does the client have a history of a warfarin, heparin, low-molecular-weight heparin (LMWH), or other antihemophilic agent in the last 60 days? [ ] (Deny) [ ] (Go to #8) 8. Has the client received less than or equal to ( ) 5 days total supply of ketorolac therapy in the last 30 days? [ ] (Approve 1 Day) [ ] (Deny) August 11, 2017 Copyright 2017 Health Information Designs, LLC 22

23 Ketorolac, Injectable/Nasal Ketorolac Injectable/Nasal Clinical Criteria Logic Diagram Step 1 Step 2 Is the request for injectable ketorolac? Is the client 2 years of age? Deny Request Step 3 Step 4 Step 5 Is the request for nasal ketorolac? Is the client 18 years of age? Does the client have a diagnosis of PUD, GI bleed, ARF or coagulation disorder in the last 730 days? Deny Request Step 6 Deny Request Deny Request Does the client have a history of an aspirin or NSAID agent in the last 30 days? Deny Request Step 7 Does the client have a history of a warfarin, heparin, LMWH or other antihemophilic agent in the last 60 days? Deny Request Step 8 Has the client received 5 days total supply of ketorolac therapy in the last 30 days? Deny Request Approve Request (1 day) August 11, 2017 Copyright 2017 Health Information Designs, LLC 23

24 Ketorolac, Injectable/Nasal Ketorolac Injectable/Nasal Clinical Criteria Supporting Tables Step 2 (diagnosis of Peptic Ulcer Disease (PUD), GI bleed, Advanced Renal Failure (ARF), or coagulation disorder) Required diagnosis: 1 Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the PUD, GI Bleed, ARF, and Coagulation Disorder Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days For the list of agents that pertain to this step, see the Aspirin and NSAID Agents table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 4 (history of warfarin, heparin, low-molecular-weight heparin (LMWH) or other antihemophilic drug) Look back timeframe: 60 days For the list of agents that pertain to this step, see the Warfarin, Heparin, LMWH, and Other Antihemophilic Drugs table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. August 11, 2017 Copyright 2017 Health Information Designs, LLC 24

25 Ketorolac, Injectable/Nasal Step 5 (received less than or equal to 5 days total supply of ketorolac therapy) Look back timeframe: 30 days For the list of therapies that pertain to this step, see the Ketorolac Therapies table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. August 11, 2017 Copyright 2017 Health Information Designs, LLC 25

26 Ketorolac Ketorolac Clinical Criteria References 1. Toradol Prescribing Information. Nutley, NJ. Roche Pharmaceuticals. vember American Medical Association data files ICD-9-CM Diagnosis Codes. Available at 3. American Medical Association data files ICD-10-CM Diagnosis Codes. Available at 4. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on June 9, Micromedex [online database]. Available at Accessed on June 9, Ketorolac Prescribing Information. Schaumburg, IL. Sagent Pharmaceuticals. February Sprix Prescribing Information. Shirley, NY. American Regent, Inc. July August 11, 2017 Copyright 2017 Health Information Designs, LLC 26

27 Ketorolac 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 07/12/2012 Initial publication and posting to website 04/03/2015 Updated to include ICD-10s 06/07/2015 Updated to include for Sprix nasal spray 08/11/2017 Annual review by staff Updated Table 3, pages Updated Table 4, pages Updated criteria logic and diagram to include age checks, pages Updated references, page 26 August 11, 2017 Copyright 2017 Health Information Designs, LLC 27

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 Oral Drugs requiring prior authorization: the list of drugs requiring prior

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 COX-2 Inhibitors Clinical Edit Information Included in this Document COX-2 Inhibitors Celebrex Drugs requiring prior authorization:

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 - Oral Drugs requiring prior authorization: the list of drugs requiring prior

More information

Prior Authorization Neurontin (gabapentin) 2016

Prior Authorization Neurontin (gabapentin) 2016 Drugs Requiring Prior Authorization Label Name GCN GABAPENTIN 100 MG CAPSULE 00780 GABAPENTIN 300 MG CAPSULE 00781 GABAPENTIN 400 MG CAPSULE 00782 GABAPENTIN 250 MG/5 ML SOLN 13235 GABAPENTIN 600 MG TABLET

More information

FDA strengthens warning that non-aspirin nonsteroidal antiinflammatory drugs (NSAIDs) can cause heart attacks or strokes

FDA strengthens warning that non-aspirin nonsteroidal antiinflammatory drugs (NSAIDs) can cause heart attacks or strokes FDA strengthens warning that non-aspirin nonsteroidal antiinflammatory drugs (NSAIDs) can cause heart attacks or strokes Safety Announcement [7-9-2015] The U.S. Food and Drug Administration (FDA) is strengthening

More information

Diclofenac 3% Gel, Diclofenac 1.5% and 2% Topical Solution

Diclofenac 3% Gel, Diclofenac 1.5% and 2% Topical Solution Texas Prior Authorization Program Clinical Criteria Drug/Drug Class, Diclofenac 1.5% and 2% Topical Solution This criteria was recommended for review by an MCO to ensure appropriate and safe utilization

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 Thiazolidinediones Clinical Edit Information Included in this Document Thiazolidinediones Drugs requiring prior authorization: the

More information

I. Mechanisms of action the role of prostaglandins a. Mediators of inflammation b. and much more

I. Mechanisms of action the role of prostaglandins a. Mediators of inflammation b. and much more NSAID steroid update Leo Semes, OD, FAAO I. Mechanisms of action the role of prostaglandins a. Mediators of inflammation b. and much more II. Topical NSAIDS ophthalmic application III. Oral NSAIDs a. Precautions

More information

Information for Vermont Prescribers of Prescription Drugs

Information for Vermont Prescribers of Prescription Drugs Information for Vermont Prescribers of Prescription Drugs ARTHROTEC (diclofenac sodium/misoprostol) tablets This list does not imply that the products on this chart are interchangeable or have the same

More information

Drug Class Review Nonsteroidal Antiinflammatory Drugs (NSAIDs)

Drug Class Review Nonsteroidal Antiinflammatory Drugs (NSAIDs) Drug Class Review Nonsteroidal Antiinflammatory Drugs (NSAIDs) Final Update 4 Report November 2010 The purpose of the is to summarize key information contained in the Drug Effectiveness Review Project

More information

Information for Vermont Prescribers of Prescription Drugs

Information for Vermont Prescribers of Prescription Drugs Information for Vermont Prescribers of Prescription Drugs ARTHROTEC (diclofenac sodium/misoprostol) tablets This list does not imply that the products on this chart are interchangeable or have the same

More information

2018 WPS MedicareRx Plan (PDP) Step Therapy

2018 WPS MedicareRx Plan (PDP) Step Therapy 2018 WPS MedicareRx Plan (PDP) Step Therapy In some cases, the WPS MedicareRx Plan (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet COLCRYS-PST Mitigare 0.6 mg capsule Colcrys 0.6 mg tablet Criteria If the patient has tried one Step 1 product, authorization for a Step 2 product may be given. Exceptions can be made for a step 2 drug

More information

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet

COLCRYS-PST. Products Affected Step 1: Mitigare 0.6 mg capsule. Details. Step 2: Colcrys 0.6 mg tablet COLCRYS-PST Mitigare 0.6 mg capsule Colcrys 0.6 mg tablet Criteria If the patient has tried one Step 1 product, authorization for a Step 2 product may be given. Exceptions can be made for a step 2 drug

More information

Texas Prior Authorization Program Clinical Criteria

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

More information

Amitiza (Lubiprostone)

Amitiza (Lubiprostone) 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

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

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document DPP-4 Inhibitor Criteria A: Alogliptin 6.25mg, Januvia 25mg, Nesina 6.25mg, Onglyza

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

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Combination Agents

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Combination Agents Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Combination Agents This criteria was recommended for review by an MCO to ensure appropriate

More information

Month/Year of Review: January 2012 Date of Last Review: February 2007

Month/Year of Review: January 2012 Date of Last Review: February 2007 Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-945-5220 Fax 503-947-1119 Month/Year of Review: January 2012 Date of Last Review:

More information

NSAIDs. NSAIDs are important but they can have side effects.

NSAIDs. NSAIDs are important but they can have side effects. NSAIDs Pain Treatment Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended for initial treatment of pain and can be added to more powerful drugs to treat worse pain. Acetaminophen, such

More information

Literature Scan: NSAIDs

Literature Scan: NSAIDs 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

These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details.

These programs and quantity limitations may not apply. Check your certificate or other plan information for benefit details. FlexRx Standard Utilization Management (PA, QL,) Updates January 1, 2018 How to use this drug list This drug list includes updates to Utilization Management (UM) programs. UM may include a prior authorization

More information

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12

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 Xifaxan 200mg Drugs requiring prior authorization: the list of drugs requiring

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: (Duexis) Reference Number: CP.PMN.120 Effective Date: 06.01.18 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy

More information

Methylnaltrexone Bromide (Relistor)

Methylnaltrexone Bromide (Relistor) 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

in people who have heart disease

in people who have heart disease Medication Guide DUEXIS (due ex is) (ibuprofen and famotidine) tablets Read this Medication Guide before you start taking DUEXIS and each time you get a refill. There may be new information. This information

More information

Available Strengths. Cost per Rx 325 mg tablet - $ mg tablet - $ mg ER tablet - $ mg capsule - $ mg chewable tablet

Available Strengths. Cost per Rx 325 mg tablet - $ mg tablet - $ mg ER tablet - $ mg capsule - $ mg chewable tablet MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY Non-Opioids LAST REVIEW 5/9/2017 THERAPEUTIC CLASS Pain REVIEW HISTORY 2/16, 5/15 LOB AFFECTED Medi-Cal (MONTH/YEAR) This

More information

Agents for Cystic Fibrosis

Agents for Cystic Fibrosis Texas Prior Authorization Program Clinical Edit Criteria Clinical Edit Information Included in this Document Kalydeco (Ivacaftor) Drugs requiring prior authorization: the list of drugs requiring prior

More information

Medication Prior Authorization Form

Medication Prior Authorization Form Section I Member Information Name (Last, First, Middle Initial) Date of Birth WEA Trust Subscriber Number Diagnosis Page 2 1. MEDICATION 2. STRENGTH 3. DIRECTIONS 4. QUANTITY FEIBA NF NovoSeven RT HEMOFIL

More information

Texas Prior Authorization Program Clinical Criteria

Texas Prior Authorization Program Clinical Criteria Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Information Included in this Document Xifaxan 200mg Drugs requiring prior authorization: the list of drugs requiring prior authorization

More information

Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs) PATIENT & CAREGIVER EDUCATION Common Medications Containing Aspirin and Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs) This information will help you identify medications that contain aspirin and

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 Provigil (Modafinil) Drugs requiring prior authorization: the list of drugs

More information

Texas Prior Authorization Program Clinical Criteria

Texas Prior Authorization Program Clinical Criteria Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Aldurazyme Adagen Carbaglu Ceprotin Elaprase Fabrazyme Lumizyme Naglazyme Orfandin Ravicti Vimizim Note: Click the hyperlink to navigate

More information

Texas Prior Authorization Program Clinical Criteria. This criteria was recommended for review by an MCO to ensure appropriate and safe utilization.

Texas Prior Authorization Program Clinical Criteria. This criteria was recommended for review by an MCO to ensure appropriate and safe utilization. Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by an MCO to ensure appropriate and safe utilization. Clinical Information Included in this

More information

**If pre-procedure instructions are not followed, it is likely we will have to cancel or reschedule this injection**

**If pre-procedure instructions are not followed, it is likely we will have to cancel or reschedule this injection** Procedure Date: Procedure Check-in Time: Procedure Start Time: Check In at Diagnostic Imaging on the 2 nd Floor of the Madison Center PRE-PROCEDURE INSTRUCTIONS Please make sure to read over these instructions

More information

Byetta (Exenatide Injection)

Byetta (Exenatide Injection) 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

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: potassium (Zipsor), (Zorvolex) Reference Number: CP.CPA.280 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end

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: (Celebrex) Reference Number: CP.CPA.239 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important Reminder at the end of this policy

More information

Acetaminophen and NSAIDS. James Moriarity MD University of Notre Dame

Acetaminophen and NSAIDS. James Moriarity MD University of Notre Dame Acetaminophen and NSAIDS James Moriarity MD University of Notre Dame Lecture Goals Understand the indications for acetaminophen and NSAID use in musculoskeletal medicine Understand the role of Eicosanoids

More information

MUSCULOSKELETAL PHARMACOLOGY. A story of the inflamed

MUSCULOSKELETAL PHARMACOLOGY. A story of the inflamed MUSCULOSKELETAL PHARMACOLOGY A story of the inflamed 1 INFLAMMATION Pathophysiology Inflammation Reaction to tissue injury Caused by release of chemical mediators Leads to a vascular response Fluid and

More information

Fentanyl Agents Clinical Edit Criteria

Fentanyl Agents Clinical Edit Criteria Fentanyl Agents Clinical Edit Criteria Drug/Drug Class: Fentanyl Agents Superior HealthPlan follows the guidance of the Texas Vendor Drug Program (VDP) for all clinical edit criteria. Superior has adjusted

More information

Lidoderm (Lidocaine) Patch

Lidoderm (Lidocaine) Patch 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

Drug Class Review Nonsteroidal Antiinflammatory Drugs (NSAIDs)

Drug Class Review Nonsteroidal Antiinflammatory Drugs (NSAIDs) Drug Class Review Nonsteroidal Antiinflammatory Drugs (NSAIDs) Final Update 4 Report November 2010 The purpose of reports is to make available information regarding the comparative clinical effectiveness

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

Xyrem (Sodium Oxybate)

Xyrem (Sodium Oxybate) Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization

More information

Quarterly Pharmacy Formulary Change Notice

Quarterly Pharmacy Formulary Change Notice Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our December 18, 2014 Value Assessment Committee (VAC) meeting.

More information

Hypoglycemics, Lantus Insulin

Hypoglycemics, Lantus Insulin Texas Prior Authorization Program PDL Edit Criteria Drug/Drug Class Hypoglycemics, Lantus Insulin Information Included in this Document Hypoglycemics, Lantus Insulin Drugs requiring prior authorization:

More information

Texas Prior Authorization Program Clinical Edit Criteria. H.P. Acthar

Texas Prior Authorization Program Clinical Edit Criteria. H.P. Acthar 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

532.6 (chronic or unspecified duodenal

532.6 (chronic or unspecified duodenal Supplementary table 1: ICD-9 and ICD-10 codes used for the identification of major bleeding and endoscopy Bleeding episode type ICD-9 codes ICD-10 codes Intracranial 430 (Subarachnoid), 431 (intracerebral),

More information

AETNA BETTER HEALTH January 2017 Formulary Change(s)

AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 Drug Name, Strength, Dosage Form IVERMECTIN 3 MG TABLET

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

Victoza (Liraglutide) Solution for Injection

Victoza (Liraglutide) Solution for Injection 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

2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)

2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) 2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to

More information

Trinity Mother Frances Orthopedics and Sports Medicine. With the help of your doctor, you have made the decision to have surgery.

Trinity Mother Frances Orthopedics and Sports Medicine. With the help of your doctor, you have made the decision to have surgery. Trinity Mother Frances Orthopedics and Sports Medicine With the help of your doctor, you have made the decision to have surgery. = APPOINTMENT PROCESS INFORMATION = You might need several different appointments

More information

Injectable Agents for the Treatment of Pulmonary Arterial Hypertension (PAH)

Injectable Agents for the Treatment of Pulmonary Arterial Hypertension (PAH) Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Injectable Agents for the Treatment of Pulmonary Arterial Hypertension (PAH) Clinical Edit Information Included in this Document

More information

Guide to Perioperative Medication Bleed and Thromboembolism Management Considerations

Guide to Perioperative Medication Bleed and Thromboembolism Management Considerations Guide to Perioperative Medication Bleed and Thromboembolism Management Considerations Start Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 7 10 days prior to Perform Medication Reconciliation Table 1:

More information

Non-steroidal Anti-Inflammatory Drugs (Oral/Rectal)

Non-steroidal Anti-Inflammatory Drugs (Oral/Rectal) About Information on indications for use or diagnosis is assumed to be unavailable. All criteria may be applied retrospectively; prospective application is indicated with an asterisk [*]. The information

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: (Celebrex) Reference Number: CP.PMN.122 Effective Date: 01.01.07 Last Review Date: 05.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of this

More information

NSAID all (Warner-Schmidt) includes all (NSAIDs, Salicytes, and Cox-2 inhibitors)

NSAID all (Warner-Schmidt) includes all (NSAIDs, Salicytes, and Cox-2 inhibitors) Table S1. Medications categorized as s all (Warner-Schmidt) includes all (s, Salicytes, and Cox-2 inhibitors) Nonsteroidal anti-inflammatory agents Bromfenac Diclofenac Diclofenac-misoprostol Etodolac

More information

Available Strengths Limits. 10 mg tablet -- $ mg tablet -- $ mg tablet -- $ mg tablet -- $72.41 Avoid use in members over

Available Strengths Limits. 10 mg tablet -- $ mg tablet -- $ mg tablet -- $ mg tablet -- $72.41 Avoid use in members over MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Fibromyalgia P&T DATE: 5/9/2017 CLASS: Pain Management REVIEW HISTORY 9/15, 5/14, 11/12, 9/12, LOB: Medi-Cal (MONTH/YEAR)

More information

Optometric indications. Pain Management in the Optometric Practice. Optometric indications. Before treatment. Before treatment.

Optometric indications. Pain Management in the Optometric Practice. Optometric indications. Before treatment. Before treatment. Optometric indications Pain Management in the Optometric Practice Steven Ferrucci, OD, FAAO Chief, Optometry; Sepulveda VA Professor; SCCO For ocular pain, process is usually acute Need for pain relief

More information

Prior Authorization Flexeril/Amrix (cyclobenzaprine) 2017

Prior Authorization Flexeril/Amrix (cyclobenzaprine) 2017 Drugs Requiring Prior Authorization Label Name GCN AMRIX ER 15 MG CAPSULE 97959 AMRIX ER 30 MG CAPSULE 97960 CYCLOBENZAPRINE 10 MG TABLET 18020 CYCLOBENZAPRINE 5 MG TABLET 12805 CYCLOBENZAPRINE 7.5 MG

More information

AETNA BETTER HEALTH January 2017 Formulary Change(s)

AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10

More information

RxBlue 2010 ST Criteria

RxBlue 2010 ST Criteria RxBlue 2010 ST Criteria ANTIDEPRESSANTS - SARAFEM... 10 FLUOXETINE HCL... 10 SARAFEM... 10 SELFEMRA... 10 ANTIDEPRESSANTS- SSRI, SNRI... 11 CELEXA... 11 CITALOPRAM... 11 CYMBALTA... 11 EFFEXOR XR... 11

More information

Texas Prior Authorization Program Clinical Criteria. Allergen Extracts

Texas Prior Authorization Program Clinical Criteria. Allergen Extracts Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Information Included in this Document Oralair (Mixed Grass Pollens Allergen Extract)) Drugs requiring prior authorization: the

More information

Cigna Drug and Biologic Coverage Policy

Cigna Drug and Biologic Coverage Policy Cigna Drug and Biologic Coverage Policy Subject Clotting Factors and Antithrombin Effective Date... 4/15/2018 Next Review Date... 3/15/2019 Coverage Policy Number... 8007 Table of Contents Coverage Policy...

More information

Carmina F. Angeles MD/PhD 74 B Centennial Loop, Suite 100 Eugene, OR Ph (541) Fax (541)

Carmina F. Angeles MD/PhD 74 B Centennial Loop, Suite 100 Eugene, OR Ph (541) Fax (541) Carmina F. Angeles MD/PhD 74 B Centennial Loop, Suite 100 Eugene, OR 97401 Ph (541) 686.3791 Fax (541) 686.3795 DISCHARGE INSTRUCTIONS FOR ANTERIOR CERVICAL DISCECTOMY AND FUSION It is important to me

More information

You May Be at Risk. You are currently taking a non-steroidal anti-inflammatory drug (NSAID):

You May Be at Risk. You are currently taking a non-steroidal anti-inflammatory drug (NSAID): NSAIDS You May Be at Risk You are currently taking a non-steroidal anti-inflammatory drug (NSAID): Aspirin Diclofenac (Voltaren ) Diflunisal (Dolobid ) Etodolac (Lodine ) Ibuprofen (Advil ) Ketoprofen

More information

Glucagon-Like Peptide (GLP-1) Receptor Agonists Clinical Edit Criteria

Glucagon-Like Peptide (GLP-1) Receptor Agonists Clinical Edit Criteria Glucagon-Like Peptide (GLP-1) Receptor Agonists Clinical Edit Criteria Drug/Drug Class: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Superior HealthPlan follows the guidance of the Texas Vendor Drug

More information

Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria

Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria Drug/Drug Class: Flexeril/Amrix (Cyclobenzaprine) Superior HealthPlan follows the guidance of the Texas Vendor Drug Program (VDP) for all clinical

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

2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)

2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) 2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to

More information

FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR PEOPLE WITH HIGH-RISK MULTIPLE CHRONIC CONDITIONS (FMC) HEDIS (Administrative)

FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR PEOPLE WITH HIGH-RISK MULTIPLE CHRONIC CONDITIONS (FMC) HEDIS (Administrative) FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR PEOPLE WITH HIGH-RISK MULTIPLE CHRONIC CONDITIONS (FMC) APPLICATIONS OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD

More information

Clinical Policy: Toremifene (Fareston) Reference Number: CP.PMN.126 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Toremifene (Fareston) Reference Number: CP.PMN.126 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Fareston) Reference Number: CP.PMN.126 Effective Date: 04.01.10 Last Review Date: 05.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important

More information

Agents for the Treatment of Hepatitis C

Agents for the Treatment of Hepatitis C 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

disease or in clients who consume alcohol on a regular basis. bilirubin

disease or in clients who consume alcohol on a regular basis. bilirubin NON-OPIOID Acetaminophen(Tylenol) Therapeutic class: Analgesic, antipyretic Aspirin (ASA, Acetylsalicylic Acid) Analgesic, NSAID, antipyretic Non-Opioid Analgesics COMMON USES WHAT I NEED TO KNOW AS A

More information

Content on this page requires a newer version of Adobe Flash Player.

Content on this page requires a newer version of Adobe Flash Player. Content on this page requires a newer version of Adobe Flash Player. Does Aleve Interact with other Medications? Severe Interactions. These medications are not usually taken together. Consult your healthcare

More information

Flexeril/Amrix (Cyclobenzaprine)

Flexeril/Amrix (Cyclobenzaprine) 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

Cystic Fibrosis Agents

Cystic Fibrosis Agents Texas Prior Authorization Program Clinical Criteria Clinical Information Included in this Document Kalydeco (Ivacaftor) Drugs requiring prior authorization: the list of drugs requiring prior authorization

More information

** Fee-For-Service Pharmacy Provider Notice #229 May 2018 PDL Changes **

** Fee-For-Service Pharmacy Provider Notice #229 May 2018 PDL Changes ** ** Fee-For-Service Pharmacy Provider Notice #229 May 2018 PDL Changes ** August 03, 2018 Please be advised that the Department for Medicaid Services (DMS) is making changes to the Kentucky Medicaid Fee-For-Service

More information

used for dealing with anxiety. Both of the drugs are also given to patients for dealing with pain activated by damaged or hypersensitive nerves that i

used for dealing with anxiety. Both of the drugs are also given to patients for dealing with pain activated by damaged or hypersensitive nerves that i Aspirin (also classified under NSAIDs or acetylsalicylic acid). Morphine and morphine sustained release (MS-Contin, Avinza, Kadian) Oxymorphone (Opana, Opana ER) Hydrocodone with acetaminophen (Lortab

More information

Fact Sheet 2. Patient Tool Kit Types of Pain Medications. Chronic pain is pain that lasts longer than it should and serves no useful purpose.

Fact Sheet 2. Patient Tool Kit Types of Pain Medications. Chronic pain is pain that lasts longer than it should and serves no useful purpose. Sheet 2 Fact Sheet 2 Types of Pain Medications Chronic pain is pain that lasts longer than it should and serves no useful purpose. You may have heard the familiar phrase no two people are exactly alike.

More information

The first stop for professional medicines advice. Community Pharmacy NSAID Gastro-Intestinal Safety Audit

The first stop for professional medicines advice. Community Pharmacy NSAID Gastro-Intestinal Safety Audit Community Pharmacy NSAID Gastro-Intestinal Safety Audit Working with Primary Care Commissioning, Strategy and Innovation Directorate The first stop for professional medicines advice www.sps.nhs.uk Community

More information

Cystic Fibrosis Agents

Cystic Fibrosis Agents Texas Prior Authorization Program Clinical Criteria Clinical Information Included in this Document Kalydeco (Ivacaftor) Drugs requiring prior authorization: the list of drugs requiring prior authorization

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 Aldara 5% Cream Drugs requiring prior authorization: the list of drugs requiring

More information

ANTIDEPRESSANT THERAPY

ANTIDEPRESSANT THERAPY Step Therapy Paramount Medicare Enhanced Formulary 2011 Formulary ID 11110, Ver 23. CMS Approved 10-25-2011. Last Updated: 10-05-2011 ANTIDEPRESSANT THERAPY Celexa Pristiq Cymbalta Prozac Effexor Prozac

More information

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative

More information

Drug Class Review on Cyclo-oxygenase (COX)-2 Inhibitors and Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Drug Class Review on Cyclo-oxygenase (COX)-2 Inhibitors and Non-steroidal Anti-inflammatory Drugs (NSAIDs) Drug Class Review on Cyclo-oxygenase (COX)-2 Inhibitors and Non-steroidal Anti-inflammatory Drugs (NSAIDs) Final Report Update 3 Evidence Tables November 2006 Original Report Date: May 2002 Update 1 Report

More information

Algorithm for Use of Non-steroidal Anti-inflammatories (NSAIDs)

Algorithm for Use of Non-steroidal Anti-inflammatories (NSAIDs) Algorithm for Use of Non-steroidal Anti-inflammatories (NSAIDs) Page 3 Publisher Conseil du médicament www.cdm.gouv.qc.ca Coordination Anne Fortin, Pharmacist Development Conseil du médicament Fédération

More information

Please Read This Entire Packet

Please Read This Entire Packet Please Read This Entire Packet 3900 Lakeville Hwy Petaluma, Ca. 94954 415-444-2988 Dear, MR# An appointment has been scheduled for you in the Outpatient Procedure Suite, Interventional Physiatry, in Petaluma

More information

Prior Authorization Opioid Overutilization 2017

Prior Authorization Opioid Overutilization 2017 Drugs Requiring Prior Authorization Label Name ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPSULE ACETAMINOPHEN/CODEINE SOLUTION ACETAMINOPHEN/CODEINE TABLET ASCOMP/CODEINE CAPSULE BUTALBITAL/CAFFEINE/ACETAMINOPHEN/CODEINE

More information

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

HOSPITAL ADMISSION SURGERY PACKET. Pre Operative Diagnosis: Pre Scheduled Surgery for: Name: Birthdate: On the day of your surgery report to:

HOSPITAL ADMISSION SURGERY PACKET. Pre Operative Diagnosis: Pre Scheduled Surgery for: Name: Birthdate: On the day of your surgery report to: HOSPITAL ADMISSION SURGERY PACKET Pre Operative Diagnosis: Pre Scheduled Surgery for: Name: Birthdate: Physician: Allergies: (Procedure) On the day of your surgery report to: A.M. ADMISSIONS: DO NOT EAT

More information

Medication Prior Authorization Form

Medication Prior Authorization Form Policy Number: 1041 FEIBA NF Novoeight Mononine NovoSeven RT RECOMBINATE BEBULIN HEMOFIL M Xyntha Profilnine SD Koate-DVI Obizur BeneFix Monoclate-P Alphanate RIXUBIS ADVATE HUMATE-P Corifact Helixate

More information