Texas Prior Authorization Program Clinical Edit Criteria

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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

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

1 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 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 Injectable 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. July 12, 2012 Copyright 2012 Health Information Designs, LLC 1

4 Oral Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 17 years of age? [ ] Yes (Go to #2) [ ] No (Deny) 2. 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? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have a history of an aspirin or NSAID agent in the last 30 days? [ ] Yes (Deny) [ ] No (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? [ ] Yes (Deny) [ ] No (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? [ ] Yes (Go to #6) [ ] No (Deny) 6. Is the requested dose less than or equal to ( ) 40 mg per day? [ ] Yes (Approve 1 day) [ ] No (Deny) July 12, 2012 Copyright 2012 Health Information Designs, LLC 4

5 Oral Clinical Edit Criteria Logic Diagram Step 1 Step 2 Is the client 17 years of age? Yes Does the client have a diagnosis of PUD, GI Bleed, ARF, or coagulation disorder in the last 730 days? Yes Deny Request No No Step 3 Deny Request Does the client have a history of an aspirin or NSAID agent in the last 30 days? Yes Deny Request No Step 4 Deny Request Does the client have a history of a warfarin, heparin, LMWH, or other antihemophilic agent in the last 60 days? Yes Deny Request Yes No Step 6 Step 5 Is the requested dose 40mg per day? Yes Has the client received 5 days total supply of ketorolac therapy in the last 30 days? No Deny Request No Approve 1 day July 12, 2012 Copyright 2012 Health Information Designs, LLC 5

6 Oral Clinical Edit 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 ICD-9 Code 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 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 CHR STOMACH ULC W HEM CHR STOM ULC W HEM-OBSTR CHR STOMACH ULCER W PERF CHR STOM ULC W PERF-OBST July 12, 2012 Copyright 2012 Health Information Designs, LLC 6

7 Step 2 (diagnosis of Peptic Ulcer Disease (PUD), GI bleed, 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 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 AC PEPTIC ULCER NOS-OBST CHR PEPTIC ULCER W HEM July 12, 2012 Copyright 2012 Health Information Designs, LLC 7

8 Step 2 (diagnosis of Peptic Ulcer Disease (PUD), GI bleed, 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 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 V560 V561 V562 V5631 V5632 V568 RENAL DIALYSIS ENCOUNTER FT/ADJ XTRCORP DIAL CATH FIT/ADJ PERIT DIAL CATH HEMODIALYSIS TESTING PERITONEAL DIALYSIS TEST DIALYSIS ENCOUNTER, NEC Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents ADD STREN PAIN REL TABLET AGGRENOX CAPSULE SA ALL DAY PAIN RELIEF 220 MG TAB ALL DAY PAIN RLF 220 MG CAPLET July 12, 2012 Copyright 2012 Health Information Designs, LLC 8

9 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 DICLOFENAC SOD DR 50 MG TAB DICLOFENAC SOD DR 75 MG TAB DICLOFENAC SOD EC 25 MG TAB July 12, 2012 Copyright 2012 Health Information Designs, LLC 9

10 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 IBUPROFEN 600 MG TABLET IBUPROFEN 800 MG TABLET IBUPROFEN COLD SUSPENSION July 12, 2012 Copyright 2012 Health Information Designs, LLC 10

11 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN 250 MG TABLET NAPROXEN 375 MG TABLET July 12, 2012 Copyright 2012 Health Information Designs, LLC 11

12 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 SM ASPIRIN 325 MG TABLET SM ASPIRIN EC 81 MG TABLET SM CHILD ASPIRIN 81 MG CHW TAB July 12, 2012 Copyright 2012 Health Information Designs, LLC 12

13 Step 3 (history of aspirin or NSAID use) Look back timeframe: 30 days Aspirin and NSAID Agents 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 ALPHANATE 1, UNIT VIAL ALPHANATE 1, UNIT VIAL ALPHANINE SD 500 UNITS VIAL July 12, 2012 Copyright 2012 Health Information Designs, LLC 13

14 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 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 FEIBA NF 651-1,200 UNIT VIAL FEIBA NF 1,750-3,250 UNIT VIAL FRAGMIN 2,500 UNITS SYRINGE July 12, 2012 Copyright 2012 Health Information Designs, LLC 14

15 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 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 JANTOVEN 7.5 MG TABLET JANTOVEN 10 MG TABLET KOATE-DVI 250 UNIT KIT July 12, 2012 Copyright 2012 Health Information Designs, LLC 15

16 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 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 WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM 10 MG TABLET July 12, 2012 Copyright 2012 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 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 July 12, 2012 Copyright 2012 Health Information Designs, LLC 17

18 , Injectable Injectable Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization KETOROLAC 15 MG/ML VIAL KETOROLAC 30 MG/ML VIAL KETOROLAC 60 MG/ML VIAL July 12, 2012 Copyright 2012 Health Information Designs, LLC 18

19 , Injectable Injectable Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 17 years of age? [ ] Yes (Go to #2) [ ] No (Deny) 2. 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? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have a history of an aspirin or NSAID agent in the last 30 days? [ ] Yes (Deny) [ ] No (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? [ ] Yes (Deny) [ ] No (Go to #5) 5. Has the client received less than or equal to ( ) 5 days total supply of ketorolac therapy in the last 30 days? [ ] Yes (Approve 1 Day) [ ] No (Deny) July 12, 2012 Copyright 2012 Health Information Designs, LLC 19

20 , Injectable Injectable Clinical Edit Criteria Logic Diagram Step 1 Step 2 Is the client 17 years of age? Yes Does the client have a diagnosis of PUD, GI Bleed, ARF, or coagulation disorder in the last 730 days? Yes Deny Request No No Step 3 Deny Request Does the client have a history of an aspirin or NSAID agent in the last 30 days? Yes Deny Request No Step 4 Does the client have a history of a warfarin, heparin, LMWH, or other antihemophilic agent in the last 60 days? Yes Deny Request No Step 5 Has the client received 5 days total supply of ketorolac therapy in the last 30 days? No Deny Request Yes Approve 1 day July 12, 2012 Copyright 2012 Health Information Designs, LLC 20

21 , Injectable Injectable Clinical Edit 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. Note: 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. Note: 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. Note: Click the hyperlink to navigate directly to the table. July 12, 2012 Copyright 2012 Health Information Designs, LLC 21

22 , Injectable 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. Note: Click the hyperlink to navigate directly to the table. July 12, 2012 Copyright 2012 Health Information Designs, LLC 22

24 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 07/12/2012 Initial publication and posting to website July 12, 2012 Copyright 2012 Health Information Designs, LLC 24

Texas Prior Authorization Program Clinical Criteria

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