Xyrem (Sodium Oxybate)

Transcription

1 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 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 Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated step 1 of logic diagram, page 4. Yes = deny; No = go to #2 December 27, 2018 Copyright 2018 Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization XYREM 500 MG/ML ORAL SOLUTION December 27, 2018 Copyright 2018 Health Information Designs, LLC 2

3 Clinical Criteria Logic 1. Is the client less than (<) 16 years of age? [ ] Yes (Deny) [ ] No (Go to #2) 2. Does the client have a diagnosis of alcohol or substance abuse in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have an active claim for a CNS depressant agent? [ ] Yes (Deny) [ ] No (Go to #4) 4. Is the requested dose per day less than or equal to ( ) 9 grams? [ ] Yes (Go to #5) [ ] No (Deny) 5. Does the client have a diagnosis of narcolepsy or cataplexy in the last 730 days? [ ] Yes (Approve 365 days) [ ] No (Deny) December 27, 2018 Copyright 2018 Health Information Designs, LLC 3

4 Clinical Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client < 16 years of age? No Does the client have a diagnosis of alcohol or substance abuse in the last 730 days? No Does the client have an active claim for a CNS depressant agent? Yes Deny Request Yes Yes No Step 4 Deny Request Deny Request Is the requested dose per day 9 grams for the client? No Deny Request Yes Step 5 Approve Request (365 days) Yes Does the client have a diagnosis of narcolepsy or cataplexy in the last 730 days? No Deny Request December 27, 2018 Copyright 2018 Health Information Designs, LLC 4

5 Clinical Criteria Supporting Tables ICD-10 Code F1010 F10120 F10129 F1020 F1021 F10220 F10229 F1110 F11120 F11129 F1120 F1121 F11220 F11221 F11222 F11229 F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288 F1129 F1190 F1210 Step 2 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days ALCOHOL ABUSE, UNCOMPLICATED ALCOHOL ABUSE WITH INTOXICATION, UNCOMPLICATED ALCOHOL ABUSE WITH INTOXICATION, UNSPECIFIED ALCOHOL DEPENDENCE, UNCOMPLICATED ALCOHOL DEPENDENCE, IN REMISSION ALCOHOL DEPENDENCE WITH INTOXICATION, UNCOMPLICATED ALCOHOL DEPENDENCE WITH INTOXICATION, UNSPECIFIED OPIOID ABUSE, UNCOMPLICATED OPIOID ABUSE WITH INTOXICATION, UNCOMPLICATED OPIOID ABUSE WITH INTOXICATION, UNSPECIFIED OPIOID DEPENDENCE, UNCOMPLICATED OPIOID DEPENDENCE, IN REMISSION OPIOID DEPENDENCE WITH INTOXICATION, UNCOMPLICATED OPIOID DEPENDENCE WITH INTOXICATION DELIRIUM OPIOID DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OPIOID DEPENDENCE WITH INTOXICATION, UNSPECIFIED OPIOID DEPENDENCE WITH WITHDRAWAL OPIOID DEPENDENCE WITH OPIOID-INDUCED MOOD DISORDER OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED OPIOID DEPENDENCE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION OPIOID DEPENDENCE WITH OPIOID-INDUCED SLEEP DISORDER OPIOID DEPENDENCE WITH OTHER OPIOID-INDUCED DISORDER OPIOID DEPENDENCE WITH UNSPECIFIED OPIOID-INDUCED DISORDER OPIOID USE, UNSPECIFIED, UNCOMPLICATED CANNABIS ABUSE, UNCOMPLICATED December 27, 2018 Copyright 2018 Health Information Designs, LLC 5

6 ICD-10 Code F1220 F1221 F12220 F12221 F12222 F12229 F12250 F12251 F12259 F12280 F12288 F1229 F1290 F1310 F13120 F1320 F1321 F13220 F13221 F13229 F13230 F13231 F13232 F13239 F1324 F13250 F13251 Step 2 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days CANNABIS DEPENDENCE, UNCOMPLICATED CANNABIS DEPENDENCE, IN REMISSION CANNABIS DEPENDENCE WITH INTOXICATION, UNCOMPLICATED CANNABIS DEPENDENCE WITH INTOXICATION DELIRIUM CANNABIS DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE CANNABIS DEPENDENCE WITH INTOXICATION, UNSPECIFIED CANNABIS DEPENDENCE WITH PSYCHOTIC DISORDER WITH DELUSIONS CANNABIS DEPENDENCE WITH PSYCHOTIC DISORDER WITH HALLUCINATIONS CANNABIS DEPENDENCE WITH PSYCHOTIC DISORDER, UNSPECIFIED CANNABIS DEPENDENCE WITH CANNABIS-INDUCED ANXIETY DISORDER CANNABIS DEPENDENCE WITH OTHER CANNABIS-INDUCED DISORDER CANNABIS DEPENDENCE WITH UNSPECIFIED CANNABIS-INDUCED DISORDER CANNABIS USE, UNSPECIFIED, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION DELIRIUM SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL DELIRIUM SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED MOOD DISORDER SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS December 27, 2018 Copyright 2018 Health Information Designs, LLC 6

7 ICD-10 Code F13259 F1326 F1327 F13280 F13281 F13282 F13288 F1329 F1390 F1410 F14120 F1420 F1421 F14220 F14221 F14222 F14229 F1423 F1424 F14250 F14251 F14259 F14280 F14281 F14282 F14288 F1429 Step 2 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING AMNESTIC DISORDER SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING DEMENTIA SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED ANXIETY DISORDER SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEXUAL DYSFUNCTION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SLEEP DISORDER SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH OTHER SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED DISORDER SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED DISORDER SEDATIVE, HYPNOTIC, OR ANXIOLYTIC USE, UNSPECIFIED, UNCOMPLICATED COCAINE ABUSE, UNCOMPLICATED COCAINE ABUSE WITH INTOXICATION, UNCOMPLICATED COCAINE DEPENDENCE, UNCOMPLICATED COCAINE DEPENDENCE, IN REMISSION COCAINE DEPENDENCE WITH INTOXICATION, UNCOMPLICATED COCAINE DEPENDENCE WITH INTOXICATION DELIRIUM COCAINE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE COCAINE DEPENDENCE WITH INTOXICATION, UNSPECIFIED COCAINE DEPENDENCE WITH WITHDRAWAL COCAINE DEPENDENCE WITH COCAINE-INDUCED MOOD DISORDER COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED COCAINE DEPENDENCE WITH COCAINE-INDUCED ANXIETY DISORDER COCAINE DEPENDENCE WITH COCAINE-INDUCED SEXUAL DYSFUNCTION COCAINE DEPENDENCE WITH COCAINE-INDUCED SLEEP DISORDER COCAINE DEPENDENCE WITH OTHER COCAINE-INDUCED DISORDER COCAINE DEPENDENCE WITH UNSPECIFIED COCAINE-INDUCED DISORDER December 27, 2018 Copyright 2018 Health Information Designs, LLC 7

8 ICD-10 Code F1490 F1510 F15120 F1520 F1521 F15220 F15221 F15222 F15229 F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282 F15288 F1529 F1590 F1610 F16120 F1620 F1621 F16220 F16221 F16229 F1624 F16250 Step 2 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days COCAINE USE, UNSPECIFIED, UNCOMPLICATED OTHER STIMULANT ABUSE, UNCOMPLICATED OTHER STIMULANT ABUSE WITH INTOXICATION, UNCOMPLICATED OTHER STIMULANT DEPENDENCE, UNCOMPLICATED OTHER STIMULANT DEPENDENCE, IN REMISSION OTHER STIMULANT DEPENDENCE WITH INTOXICATION, UNCOMPLICATED OTHER STIMULANT DEPENDENCE WITH INTOXICATION DELIRIUM OTHER STIMULANT DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OTHER STIMULANT DEPENDENCE WITH INTOXICATION, UNSPECIFIED OTHER STIMULANT DEPENDENCE WITH WITHDRAWAL OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED MOOD DISORDER OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED ANXIETY DISORDER OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SEXUAL DYSFUNCTION OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SLEEP DISORDER OTHER STIMULANT DEPENDENCE WITH OTHER STIMULANT-INDUCED DISORDER OTHER STIMULANT DEPENDENCE WITH UNSPECIFIED STIMULANT- INDUCED DISORDER OTHER STIMULANT USE, UNSPECIFIED, UNCOMPLICATED HALLUCINOGEN ABUSE, UNCOMPLICATED HALLUCINOGEN ABUSE WITH INTOXICATION, UNCOMPLICATED HALLUCINOGEN DEPENDENCE, UNCOMPLICATED HALLUCINOGEN DEPENDENCE, IN REMISSION HALLUCINOGEN DEPENDENCE WITH INTOXICATION, UNCOMPLICATED HALLUCINOGEN DEPENDENCE WITH INTOXICATION WITH DELIRIUM HALLUCINOGEN DEPENDENCE WITH INTOXICATION, UNSPECIFIED HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED MOOD DISORDER HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS December 27, 2018 Copyright 2018 Health Information Designs, LLC 8

9 ICD-10 Code F16251 F16259 F16280 F16283 F16288 F1629 F1690 F1810 F18120 F1820 F1821 F18220 F18221 F18229 F1824 F18250 F18251 F18259 F1827 F18280 F18288 F1829 F1890 F1920 F1921 F19220 F19221 F19222 Step 2 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED ANXIETY DISORDER HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN PERSISTING PERCEPTION DISORDER (FLASHBACKS) HALLUCINOGEN DEPENDENCE WITH OTHER HALLUCINOGEN-INDUCED DISORDER HALLUCINOGEN DEPENDENCE WITH UNSPECIFIED HALLUCINOGEN- INDUCED DISORDER HALLUCINOGEN USE, UNSPECIFIED, UNCOMPLICATED INHALANT ABUSE, UNCOMPLICATED INHALANT ABUSE WITH INTOXICATION, UNCOMPLICATED INHALANT DEPENDENCE, UNCOMPLICATED INHALANT DEPENDENCE, IN REMISSION INHALANT DEPENDENCE WITH INTOXICATION, UNCOMPLICATED INHALANT DEPENDENCE WITH INTOXICATION DELIRIUM INHALANT DEPENDENCE WITH INTOXICATION, UNSPECIFIED INHALANT DEPENDENCE WITH INHALANT-INDUCED MOOD DISORDER INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED INHALANT DEPENDENCE WITH INHALANT-INDUCED DEMENTIA INHALANT DEPENDENCE WITH INHALANT-INDUCED ANXIETY DISORDER INHALANT DEPENDENCE WITH OTHER INHALANT-INDUCED DISORDER INHALANT DEPENDENCE WITH UNSPECIFIED INHALANT-INDUCED DISORDER INHALANT USE, UNSPECIFIED, UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE, UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE, IN REMISSION OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION, UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE December 27, 2018 Copyright 2018 Health Information Designs, LLC 9

10 ICD-10 Code F19229 F19230 F19231 F19232 F19239 F1924 F19250 F19251 F19259 F1926 F1927 F19280 F19281 F19282 F19288 F1929 F550 F551 F552 F553 F554 F558 Step 2 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION, UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL, UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL, UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD DISORDER OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING AMNESTIC DISORDER OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING DEMENTIA OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED ANXIETY DISORDER OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SEXUAL DYSFUNCTION OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SLEEP DISORDER OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH OTHER PSYCHOACTIVE SUBSTANCE-INDUCED DISORDER OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH UNSPECIFIED PSYCHOACTIVE SUBSTANCE-INDUCED DISORDER ABUSE OF ANTACIDS ABUSE OF HERBAL OR FOLK REMEDIES ABUSE OF LAXATIVES ABUSE OF STEROIDS OR HORMONES ABUSE OF VITAMINS ABUSE OF OTHER NON-PSYCHOACTIVE SUBSTANCES December 27, 2018 Copyright 2018 Health Information Designs, LLC 10

11 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE ELIXIR ACTIQ 1,200 MCG LOZENGE ACTIQ 1,600 MCG LOZENGE ACTIQ 200 MCG LOZENGE ACTIQ 400 MCG LOZENGE ACTIQ 600 MCG LOZENGE ACTIQ 800 MCG LOZENGE ALPRAZOLAM 0.25 MG ODT ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG ODT ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG ODT ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 1 MG/ML ORAL CONC ALPRAZOLAM 2 MG ODT ALPRAZOLAM 2 MG TABLET ALPRAZOLAM ER 0.5 MG TABLET ALPRAZOLAM ER 1 MG TABLET ALPRAZOLAM ER 2 MG TABLET ALPRAZOLAM ER 3 MG TABLET ALPRAZOLAM XR 0.5 MG TABLET ALPRAZOLAM XR 1 MG TABLET ALPRAZOLAM XR 2 MG TABLET ALPRAZOLAM XR 3 MG TABLET AMBIEN 5 MG TABLET AMBIEN 10 MG TABLET AMBIEN CR 6.25 MG TABLET AMBIEN CR 12.5 MG TABLET ASCOMP WITH CODEINE CAPSULE AVINZA 120 MG CAPSULE AVINZA 60 MG CAPSULE AVINZA 90 MG CAPSULE BELLADONNA-OPIUM SUPP December 27, 2018 Copyright 2018 Health Information Designs, LLC 11

12 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null BELLADONNA-OPIUM SUPP BUNAVAIL MG FILM BUNAVAIL MG FILM BUNAVAIL 6.3-1MG FILM BUPRENEX 0.3 MG/ML AMPUL BUPRENORPHINE 2 MG TABLET SL BUPRENORPHINE 8 MG TABLET SL BUPRENORPHN-NALOXON MG SL BUPRENORPHN-NALOXON 8-2 MG SL BUTALB-CAFF-ACETAMINOPH-CODEIN BUTALB-CAFF-ACETAMINOPH-CODEIN BUTISOL SODIUM 30 MG TABLET BUTORPHANOL 10 MG/ML SPRAY BUTRANS 10 MCG/HR PATCH BUTRANS 15 MCG/HR PATCH BUTRANS 20 MCG/HR PATCH BUTRANS 5 MCG/HR PATCH BUTRANS 7.5 MCG/HR PATCH CAPITAL WITH CODEINE SUSP CARISOPRODOL CPD-CODEINE TAB CHLORDIAZEPOXIDE 5 MG CAPSULE CHLORDIAZEPOXIDE 10 MG CAPSULE CHLORDIAZEPOXIDE 25 MG CAPSULE CHLORDIAZEPOXIDE-CLIDINIUM CAPSULE CLONAZEPAM MG DIS TAB CLONAZEPAM 0.5 MG DIS TABLET CLONAZEPAM 1 MG DIS TABLET CLONAZEPAM 0.25 MG ODT CLONAZEPAM 2 MG ODT CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1 MG TABLET CLONAZEPAM 2 MG TABLET CLORAZEPATE 3.75 MG TABLET CLORAZEPATE 7.5 MG TABLET CLORAZEPATE 15 MG TABLET CODEINE SULFATE 30 MG TABLET December 27, 2018 Copyright 2018 Health Information Designs, LLC 12

13 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null CODEINE SULFATE 60 MG TABLET DEMEROL 100 MG/ML AMPUL DEMEROL 100 MG/ML VIAL DEMEROL 50 MG TABLET DEMEROL 50 MG/ML AMPUL DEMEROL 50 MG/ML AMPUL DEMEROL 50 MG/ML VIAL DEMEROL 75 MG/1.5 ML AMPUL DIAZEPAM 5 MG/ML ORAL CONC DIAZEPAM 2.5 MG RECTAL GEL DIAZEPAM 5 MG/5 ML SOLUTION DIAZEPAM 2 MG TABLET DIAZEPAM 5 MG TABLET DIAZEPAM 10 MG TABLET DIHYDROCODEIN-ACETAMINOPH-CAFF DILAUDID 2 MG TABLET DILAUDID 4 MG TABLET DILAUDID 8 MG TABLET DILAUDID-5 1 MG/ML LIQUID DILAUDID-HP 10 MG/ML AMPUL DILAUDID-HP 250 MG VIAL DOLOPHINE HCL 10 MG TABLET DURAGESIC 100 MCG/HR PATCH DURAGESIC 12 MCG/HR PATCH DURAGESIC 25 MCG/HR PATCH DURAGESIC 50 MCG/HR PATCH DURAGESIC 75 MCG/HR PATCH EDLUAR 5 MG SL TABLET EDLUAR 10 MG SL TABLET EMBEDA ER 100-4MG CAPSULE EMBEDA ER MG CAPSULE EMBEDA ER MG CAPSULE EMBEDA ER 50-2MG CAPSULE EMBEDA ER MG CAPSULE EMBEDA ER MG CAPSULE ENDOCET MG TABLET December 27, 2018 Copyright 2018 Health Information Designs, LLC 13

14 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null ENDOCET MG TABLET ENDOCET TABLET ENDOCET MG TABLET ESTAZOLAM 1 MG TABLET ESTAZOLAM 2 MG TABLET EXALGO ER 12 MG TABLET EXALGO ER 16 MG TABLET EXALGO ER 32 MG TABLET EXALGO ER 8 MG TABLET FENTANYL 100 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH FENTANYL 25 MCG/HR PATCH FENTANYL 37.5 MCG/HR PATCH FENTANYL 50 MCG/HR PATCH FENTANYL 62.5 MCG/HR PATCH FENTANYL 75 MCG/HR PATCH FENTANYL 87.5 MCG/HR PATCH FENTANYL CIT OTFC 1,200 MCG FENTANYL CIT OTFC 1,600 MCG FENTANYL CITRATE OTFC 200 MCG FENTANYL CITRATE OTFC 400 MCG FENTANYL CITRATE OTFC 600 MCG FENTANYL CITRATE OTFC 800 MCG FENTORA 100 MCG BUCCAL TABLET FENTORA 200 MCG BUCCAL TABLET FENTORA 400 MCG BUCCAL TABLET FENTORA 600 MCG BUCCAL TABLET FENTORA 800 MCG BUCCAL TABLET FIORICET-COD CAP FIORINAL-COD CAP FLURAZEPAM 15 MG CAPSULE FLURAZEPAM 30 MG CAPSULE HYCET 7.5 MG-325 MG/15 ML SOL HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPH December 27, 2018 Copyright 2018 Health Information Designs, LLC 14

15 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null HYDROCODON-ACETAMINOPHEN HYDROCODON-ACETAMINOPHEN HYDROCODON-ACETAMINOPHN HYDROCODON-ACETAMINOPHN HYDROCODONE-ACETAMINOPHEN SOLN HYDROCODONE BT-IBUPROFEN TAB HYDROCODONE-IBUPROFEN HYDROCODONE-IBUPROFEN HYDROCODONE-IBUPROFEN HYDROMORPHONE 1 MG/ML SOLUTION HYDROMORPHONE 10 MG/ML VIAL HYDROMORPHONE 2 MG TABLET HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE 4 MG TABLET HYDROMORPHONE 8 MG TABLET HYSINGLA ER 100MG TABLET HYSINGLA ER 120MG TABLET HYSINGLA ER 20MG TABLET HYSINGLA ER 30MG TABLET HYSINGLA ER 40MG TABLET HYSINGLA ER 60MG TABLET HYSINGLA ER 80MG TABLET IBUDONE MG TABLET IBUDONE MG TABLET KADIAN ER 10 MG CAPSULE KADIAN ER 100 MG CAPSULE KADIAN ER 20 MG CAPSULE KADIAN ER 200 MG CAPSULE KADIAN ER 30 MG CAPSULE KADIAN ER 50 MG CAPSULE KADIAN ER 60 MG CAPSULE KADIAN ER 80 MG CAPSULE KLONOPIN 0.5 MG TABLET KLONOPIN 1 MG TABLET KLONOPIN 2 MG TABLET LAZANDA 100MCG SPRAY/PUMP December 27, 2018 Copyright 2018 Health Information Designs, LLC 15

16 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null LAZANDA 300 MCG NASAL SPRAY LAZANDA 400MCG SPRAY/PUMP LEVORPHANOL 2 MG TABLET LORAZEPAM 0.5 MG TABLET LORAZEPAM 1 MG TABLET LORAZEPAM 2 MG TABLET LORAZEPAM 2 MG/ML VIAL LORAZEPAM 4 MG/ML VIAL LORAZEPAM INTENSOL 2 MG/ML LORCET MG TABLET LORCET HD MG TABLET LORCET PLUS MG TABLET LORTAB TABLET LORTAB TABLET LORTAB TABLET LUNESTA 1 MG TABLET LUNESTA 2 MG TABLET LUNESTA 3 MG TABLET MEPERIDINE 100 MG TABLET MEPERIDINE 100 MG/ML VIAL MEPERIDINE 25 MG/ML VIAL MEPERIDINE 50 MG TABLET MEPERIDINE 50 MG/5 ML SOLUTION MEPERIDINE 50 MG/ML VIAL MEPROBAMATE 200 MG TABLET MEPROBAMATE 400 MG TABLET METHADONE 10 MG/5 ML SOLUTION METHADONE 10 MG/ML ORAL CONC METHADONE 40 MG TABLET DISPR METHADONE 5 MG/5 ML SOLUTION METHADONE HCL 10 MG TABLET METHADONE HCL 5 MG TABLET METHADONE INTENSOL 10 MG/ML METHADOSE 10 MG TABLET METHADOSE 40 MG TABLET DISPR MORPHINE 10 MG/ML CARPUJECT December 27, 2018 Copyright 2018 Health Information Designs, LLC 16

17 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null MORPHINE 15 MG/ML CARPUJECT MORPHINE 15 MG/ML VIAL MORPHINE 2 MG/ML CARPUJECT MORPHINE 4 MG/ML CARPUJECT MORPHINE 8 MG/ML SYRINGE MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULF 100 MG/5 ML SOLN MORPHINE SULF 10MG/ML VIAL MORPHINE SULF 20 MG/5 ML SOLN MORPHINE SULF 5 MG/ML VIAL MORPHINE SULF 8 MG/ML VIAL MORPHINE SULF CR 15 MG TABLET MORPHINE SULF CR 30 MG TABLET MORPHINE SULF CR 60 MG TABLET MORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE 50 MG/ML VIAL MORPHINE SULFATE ER 100MG CAP MORPHINE SULFATE ER 10MG CAP MORPHINE SULFATE ER 120MG CAP MORPHINE SULFATE ER 20MG CAP MORPHINE SULFATE ER 30MG CAP MORPHINE SULFATE ER 30MG CAP MORPHINE SULFATE ER 45MG CAP MORPHINE SULFATE ER 50MG CAP MORPHINE SULFATE ER 60MG CAP MORPHINE SULFATE ER 60MG CAP MORPHINE SULFATE ER 75MG CAP MORPHINE SULFATE ER 80 MG CAP MORPHINE SULFATE ER 90MG CAP MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE IR 30 MG TAB MS CONTIN 100 MG TABLET MS CONTIN 15 MG TABLET MS CONTIN 200 MG TABLET December 27, 2018 Copyright 2018 Health Information Designs, LLC 17

18 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null MS CONTIN 60 MG TABLET MS CONTIN CR 30 MG TABLET NALBUPHINE 10 MG/ML AMPUL NALBUPHINE 200 MG/10 ML VIAL NIRAVAM 0.25 MG ODT NIRAVAM 0.5 MG ODT NIRAVAM 1 MG ODT NIRAVAM 2 MG ODT NORCO TABLET NUCYNTA 100 MG TABLET NUCYNTA 50 MG TABLET NUCYNTA 75 MG TABLET NUCYNTA ER 100MG TABLET NUCYNTA ER 150MG TABLET NUCYNTA ER 200MG TABLET NUCYNTA ER 250MG TABLET NUCYNTA ER 50MG TABLET OPANA 10 MG TABLET OPANA 5 MG TABLET OPANA ER 10 MG TABLET OPANA ER 15 MG TABLET OPANA ER 20 MG TABLET OPANA ER 30 MG TABLET OPANA ER 40 MG TABLET OPANA ER 5 MG TABLET OPANA ER 7.5 MG TABLET OPIUM TINCTURE 10 MG/ML OXAZEPAM 10 MG CAPSULE OXAZEPAM 15 MG CAPSULE OXAZEPAM 30 MG CAPSULE OXYCODON-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN OXYCODON-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN OXYCODONE-ASA TABLET OXYCODONE CONC 20 MG/ML SOLN December 27, 2018 Copyright 2018 Health Information Designs, LLC 18

19 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null OXYCODONE HCL 10 MG TABLET OXYCODONE HCL 10 MG TABLET ER OXYCODONE HCL 15 MG TABLET OXYCODONE HCL 20 MG TABLET OXYCODONE HCL 20 MG TABLET ER OXYCODONE HCL 30 MG TABLET OXYCODONE HCL 40 MG TABLET ER OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL 5 MG TABLET OXYCODONE HCL 5 MG/5 ML SOL OXYCODONE HCL ER 80 MG TABLET OXYCODONE-IBUPROFEN TAB OXYCONTIN 10 MG TABLET OXYCONTIN 15 MG TABLET OXYCONTIN 20 MG TABLET OXYCONTIN 30 MG TABLET OXYCONTIN 40 MG TABLET OXYCONTIN 60 MG TABLET OXYCONTIN 80 MG TABLET OXYMORPHONE HCL 5 MG TABLET OXYMORPHONE HCL 10 MG TABLET OXYMORPHONE HCL ER 10 MG TAB OXYMORPHONE HCL ER 15 MG TAB OXYMORPHONE HCL ER 20 MG TAB OXYMORPHONE HCL ER 30 MG TAB OXYMORPHONE HCL ER 40 MG TAB OXYMORPHONE HCL ER 5 MG TABLET OXYMORPHONE HCL ER 7.5 MG TAB PENTAZOCINE-NALOXONE TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCOCET MG TABLET PHENOBARBITAL 20 MG/5 ML ELIX PHENOBARBITAL 15 MG TABLET PHENOBARBITAL 16.2 MG TABLET December 27, 2018 Copyright 2018 Health Information Designs, LLC 19

20 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null PHENOBARBITAL 30 MG TABLET PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL 60 MG TABLET PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL 97.2 MG TABLET PHENOBARBITAL 100 MG TABLET PHENOBARBITAL 65 MG/ML VIAL PHENOBARBITAL 130 MG/ML VIAL REPREXAIN MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET RESTORIL 7.5 MG CAPSULE RESTORIL 15 MG CAPSULE RESTORIL 22.5 MG CAPSULE RESTORIL 30 MG CAPSULE ROXICODONE 15 MG TABLET ROXICODONE 30 MG TABLET ROZEREM 8 MG TABLET SONATA 5 MG CAPSULE SONATA 10 MG CAPSULE SUBOXONE 12MG 3MG FILM SUBOXONE 2MG 0.5MG FILM SUBOXONE 4MG 1MG FILM SUBOXONE 8MG 2MG FILM TEMAZEPAM 7.5 MG CAPSULE TEMAZEPAM 15 MG CAPSULE TEMAZEPAM 22.5 MG CAPSULE TEMAZEPAM 30 MG CAPSULE TRAMADOL HCL 50 MG TABLET TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER 200 MG TABLET TRAMADOL-ACETAMINOPHN TRANXENE SD MG TABLET TRANXENE SD 22.5 MG TAB TRANXENE T-TAB 3.75 MG TRANXENE T-TAB 7.5 MG December 27, 2018 Copyright 2018 Health Information Designs, LLC 20

21 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null TRANXENE T-TAB 15 MG TRIAZOLAM 0.25 MG TABLET TRIAZOLAM MG TABLET TYLENOL WITH CODEINE #3 TABLET TYLENOL WITH CODEINE #4 TABLET ULTRACET TABLET ULTRAM 50 MG TABLET VICODIN TABLET VICODIN ES MG TABLET VICODIN HP MG TABLET VICOPROFEN MG TAB XANAX 0.25 MG TABLET XANAX 0.5 MG TABLET XANAX 1 MG TABLET XANAX 2 MG TABLET XANAX XR 0.5 MG TABLET XANAX XR 1 MG TABLET XANAX XR 2 MG TABLET XANAX XR 3 MG TABLET XARTEMIS XR MG TABLET XTAMPZA ER 9 MG CAPSULE XTAMPZA ER 13.5 MG CAPSULE XTAMPZA ER 18 MG CAPSULE XTAMPZA ER 27 MG CAPSULE XTAMPZA ER 36 MG CAPSULE XODOL TABLET XODOL MG TABLET XODOL TABLET ZALEPLON 5 MG CAPSULE ZALEPLON 10 MG CAPSULE ZEBUTAL CAPSULE ZOLPIDEM TART ER 6.25 MG TAB ZOLPIDEM TART ER 12.5 MG TAB ZOLPIDEM TARTRATE 5 MG TABLET ZOLPIDEM TARTRATE 10 MG TABLET ZUBSOLV MG TABLET SL December 27, 2018 Copyright 2018 Health Information Designs, LLC 21

22 Step 3 (active claim for CNS depressant) Required quantity: 1 Look back timeframe: Null ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLE SL ICD-10 Code G47411 G47419 G47421 G47429 Step 5 (diagnosis of narcolepsy or cataplexy) Description Required diagnosis: 1 Look back timeframe: 730 days NARCOLEPSY WITH CATAPLEXY NARCOLEPSY WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT CATAPLEXY December 27, 2018 Copyright 2018 Health Information Designs, LLC 22

23 Clinical Criteria References ICD-9-CM Diagnosis Codes Available at Accessed on April 3, ICD-10-CM Diagnosis Codes Available at Accessed on April 3, American Medical Association data files ICD-9-CM Diagnosis Codes. Available at 4. American Medical Association data files ICD-10-CM Diagnosis Codes. Available at 5. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on April 12, Micromedex [online database]. Available at Accessed on April 12, Xyrem Prescribing Information. Palo Alto, CA. Jazz Pharmaceuticals. July Krahn LE, Hershner S, Loeding LD, et al. Quality Measures for the Care of Patients with Narcolepsy. Journal of Clinical Sleep Medicine 2015;11(3): December 27, 2018 Copyright 2018 Health Information Designs, LLC 23

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 03/09/2011 Initial publication and posting to website 10/26/2011 Added a new section to specify the drugs requiring prior authorization Modified criteria logic and logic diagram to identify the steps that are executed manually In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the drug names and s pertinent to steps 3 and 5 of the logic diagram In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 4 and 7 of the logic diagram 04/03/2015 Updated to include ICD-10s 04/12/2018 Annual review by staff Removed ICD-9 codes Updated logic and logic diagram, pages 3-4 Updated Table 3, page /27/2018 Updated step 1 of logic diagram, page 4. Yes = deny; No = go to #2 December 27, 2018 Copyright 2018 Health Information Designs, LLC 24