Texas Prior Authorization Program Clinical Edit Criteria

Transcription

1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical edit Note: Click the hyperlink to navigate directly to that section. Revision Notes Initial publication and posting to website April 3, 2012 Copyright 2012 Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name RANEXA ER 500 MG TABLET RANEXA ER 1,000 MG TABLET April 3, 2012 Copyright 2012 Health Information Designs, LLC 2

3 Clinical Edit Criteria Logic 1. Does the client have a diagnosis of chronic angina in the past 730 days? [ ] Yes (Go to #2) [ ] No (Deny) 2. Has the client received greater than or equal to ( ) 30 days of therapy with a first-line agent in the past 365 days? [ ] Yes (Go to #4) [ ] No (Go to #3) 3. Does the client have a history of greater than or equal to ( ) 90 days of therapy with ranolazine in the past 120 days? [ ] Yes (Go to #4) [ ] No (Deny) 4. Does the client have a diagnosis of clinically-significant hepatic impairment in the past 365 days? [ ] Yes (Deny) [ ] No (Go to step #5) 5. Does the client have a history of a drug that is contraindicated with ranolazine in the past 30 days? [ ] Yes (Deny) [ ] No (Approve 365 days) April 3, 2012 Copyright 2012 Health Information Designs, LLC 3

4 Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 4 Does the client have a diagnosis of chronic angina in the past 730 days? Yes Has the client received 30 days of therapy with a first-line agent in the past 365 days? Yes Does the client have a history of clinically significant hepatic impairment in the past 365 days? Yes Deny Request No No Yes No Step 3 Step 5 Deny Request Does the client have a history of 90 days of therapy with ranolazine in the past 120 days? Does the client have a history of a drug that is contraindicated with ranolazine in the past 30 days? Yes Deny Request No No Deny Request Approve (365 days) April 3, 2012 Copyright 2012 Health Information Designs, LLC 4

5 Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of chronic angina) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code 4130 ANGINA DECUBITUS 4131 PRINZMETAL ANGINA 4139 ANGINA PECTORIS NEC/NOS Step 2 ( 30 days of therapy with first-line agent) ACEBUTOLOL 200 MG CAPSULE ACEBUTOLOL 400 MG CAPSULE ADALAT CC 30 MG TABLET ADALAT CC 60 MG TABLET ADALAT CC 90 MG TABLET AFEDITAB CR 30 MG TABLET AFEDITAB CR 60 MG TABLET AMLODIPINE BESYLATE 2.5 MG TAB AMLODIPINE BESYLATE 5 MG TAB AMLODIPINE BESYLATE 10 MG TAB AMLODIPINE-BENAZEPRIL AMLODIPINE-BENAZEPRIL 5-10 MG AMLODIPINE-BENAZEPRIL 5-20 MG AMLODIPINE-BENAZEPRIL 5-40 MG AMLODIPINE-BENAZEPRIL MG AMLODIPINE-BENAZEPRIL MG ATENOLOL 25 MG TABLET ATENOLOL 50 MG TABLET ATENOLOL 100 MG TABLET ATENOLOL-CHLORTHAL TB ATENOLOL-CHLORTHALIDONE April 3, 2012 Copyright 2012 Health Information Designs, LLC 5

6 Step 2 ( 30 days of therapy with first-line agent) AZOR 5-20 MG TABLET AZOR 5-40 MG TABLET AZOR MG TABLET AZOR MG TABLET BETAXOLOL 10 MG TABLET BETAXOLOL 20 MG TABLET BIDIL TABLET BISOPROLOL FUMARATE 5 MG TAB BISOPROLOL FUMARATE 10 MG TAB BISOPROLOL-HCTZ MG TB BISOPROLOL-HCTZ MG TAB BISOPROLOL-HCTZ MG TAB CADUET 10 MG-10 MG TABLET CADUET 10 MG-20 MG TABLET CADUET 10 MG-40 MG TABLET CADUET 10 MG-80 MG TABLET CADUET 5 MG-10 MG TABLET CADUET 5 MG-20 MG TABLET CADUET 5 MG-40 MG TABLET CADUET 5 MG-80 MG TABLET CORGARD 20 MG TABLET CORGARD 40 MG TABLET CORGARD 80 MG TABLET CORZIDE 40-5 TABLET CORZIDE 80-5 TABLET DILATRATE-SR 40 MG CAPSULE DYNACIRC CR 10 MG TABLET EXFORGE MG TABLET EXFORGE MG TABLET EXFORGE MG TABLET EXFORGE MG TABLET EXFORGE HCT MG TAB EXFORGE HCT MG TAB EXFORGE HCT MG TAB EXFORGE HCT MG TAB April 3, 2012 Copyright 2012 Health Information Designs, LLC 6

7 Step 2 ( 30 days of therapy with first-line agent) EXFORGE HCT MG TAB FELODIPINE ER 2.5 MG TABLET FELODIPINE ER 5 MG TABLET FELODIPINE ER 10 MG TABLET IMDUR ER 30 MG TABLET IMDUR ER 60 MG TABLET IMDUR ER 120 MG TABLET INDERAL LA 60 MG CAPSULE INDERAL LA 80 MG CAPSULE INDERAL LA 120 MG CAPSULE INDERAL LA 160 MG CAPSULE INNOPRAN XL 80 MG CAPSULE INNOPRAN XL 120 MG CAPSULE ISMO 20 MG TABLET ISORDIL 40 MG TABLET ISOSORBIDE DN 2.5 MG TAB SL ISOSORBIDE DN 5 MG TABLET ISOSORBIDE DN 5 MG TABLET SL ISOSORBIDE DN 10 MG TABLET ISOSORBIDE DN 20 MG TABLET ISOSORBIDE DN 30 MG TABLET ISOSORBIDE DN ER 40 MG TABLET ISOSORBIDE MN 10 MG TABLET ISOSORBIDE MN 20 MG TABLET ISOSORBIDE MN ER 30 MG TABLET ISOSORBIDE MN ER 60 MG TABLET ISOSORBIDE MN ER 120 MG TAB ISRADIPINE 2.5 MG CAPSULE ISRADIPINE 5 MG CAPSULE LEVATOL 20 MG TABLET LOPRESSOR 50 MG TABLET LOPRESSOR 100 MG TABLET LOTREL MG CAPSULE LOTREL 5-10 MG CAPSULE LOTREL 5-20 MG CAPSULE April 3, 2012 Copyright 2012 Health Information Designs, LLC 7

8 Step 2 ( 30 days of therapy with first-line agent) LOTREL 5-40 MG CAPSULE LOTREL MG CAPSULE LOTREL MG CAPSULE METOPROLOL SUCC ER 25 MG TAB METOPROLOL SUCC ER 50 MG TAB METOPROLOL SUCC ER 100 MG TAB METOPROLOL SUCC ER 200 MG TAB METOPROLOL TARTRATE 25 MG TAB METOPROLOL TARTRATE 50 MG TAB METOPROLOL TARTRATE 100 MG TAB METOPROLOL-HCTZ MG TAB METOPROLOL-HCTZ MG TAB METOPROLOL-HCTZ MG TAB MINITRAN 0.1 MG/HR PATCH MINITRAN 0.2 MG/HR PATCH MINITRAN 0.4 MG/HR PATCH MINITRAN 0.6 MG/HR PATCH MONOKET 10 MG TABLET MONOKET 20 MG TABLET NADOLOL 20 MG TABLET NADOLOL 40 MG TABLET NADOLOL 80 MG TABLET NADOLOL-BENDROFLU 40-5 MG TAB NADOLOL-BENDROFLU 80-5 MG TAB NICARDIPINE 20 MG CAPSULE NICARDIPINE 30 MG CAPSULE NIFEDIAC CC 30 MG TABLET NIFEDIAC CC 60 MG TABLET NIFEDIAC CC 90 MG TABLET NIFEDICAL XL 30 MG TABLET NIFEDICAL XL 60 MG TABLET NIFEDIPINE 10 MG CAPSULE NIFEDIPINE 20 MG CAPSULE NIFEDIPINE ER 30 MG TABLET NIFEDIPINE ER 30 MG TABLET April 3, 2012 Copyright 2012 Health Information Designs, LLC 8

9 Step 2 ( 30 days of therapy with first-line agent) NIFEDIPINE ER 60 MG TABLET NIFEDIPINE ER 60 MG TABLET NIFEDIPINE ER 90 MG TABLET NIFEDIPINE ER 90 MG TABLET NISOLDIPINE ER 8.5 MG TABLET NISOLDIPINE ER 17 MG TABLET NISOLDIPINE ER 25.5 MG TABLET NISOLDIPINE ER 34 MG TABLET NITRO-DUR 0.1 MG/HR PATCH NITRO-DUR 0.2 MG/HR PATCH NITRO-DUR 0.3 MG/HR PATCH NITRO-DUR 0.4 MG/HR PATCH NITRO-DUR 0.6 MG/HR PATCH NITRO-DUR 0.8 MG/HR PATCH NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN 0.3 MG TAB SL NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN 0.6 MG TAB SL NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN LINGUAL 0.4 MG NITROLINGUAL 0.4 MG SPRAY NITROQUICK 0.3 MG TABLET SL NITROQUICK 0.4 MG TABLET SL NITROQUICK 0.6 MG TABLET SL NITROSTAT 0.3 MG TABLET SL NITROSTAT 0.4 MG TABLET SL NITROSTAT 0.6 MG TABLET SL NORVASC 2.5 MG TABLET NORVASC 5 MG TABLET NORVASC 10 MG TABLET PINDOLOL 5 MG TABLET PINDOLOL 10 MG TABLET April 3, 2012 Copyright 2012 Health Information Designs, LLC 9

10 Step 2 ( 30 days of therapy with first-line agent) PROCARDIA 10 MG CAPSULE PROCARDIA XL 30 MG TABLET PROCARDIA XL 60 MG TABLET PROCARDIA XL 90 MG TABLET PROPRANOLOL 10 MG TABLET PROPRANOLOL 20 MG TABLET PROPRANOLOL 20 MG/5 ML SOLN PROPRANOLOL 40 MG TABLET PROPRANOLOL 40 MG/5 ML SOLN PROPRANOLOL 60 MG TABLET PROPRANOLOL 80 MG TABLET PROPRANOLOL ER 60 MG CAPSULE PROPRANOLOL ER 80 MG CAPSULE PROPRANOLOL ER 120 MG CAPSULE PROPRANOLOL ER 160 MG CAPSULE PROPRANOLOL-HCTZ MG TAB PROPRANOLOL-HCTZ MG TAB SECTRAL 200 MG CAPSULE SECTRAL 400 MG CAPSULE SULAR ER 8.5 MG TABLET SULAR ER 17 MG TABLET SULAR ER 25.5 MG TABLET SULAR ER 34 MG TABLET TEKAMLO 150 MG-5 MG TABLET TEKAMLO 150 MG-10 MG TABLET TEKAMLO 300 MG-5 MG TABLET TEKAMLO 300 MG-10 MG TABLET TENORETIC 50 TABLET TENORETIC 100 TABLET TENORMIN 25 MG TABLET TENORMIN 50 MG TABLET TENORMIN 100 MG TABLET TIMOLOL MALEATE 5 MG TABLET TIMOLOL MALEATE 10 MG TABLET TIMOLOL MALEATE 20 MG TABLET April 3, 2012 Copyright 2012 Health Information Designs, LLC 10

11 Step 2 ( 30 days of therapy with first-line agent) TOPROL XL 25 MG TABLET TOPROL XL 50 MG TABLET TOPROL XL 100 MG TABLET TOPROL XL 200 MG TABLET TRIBENZOR MG TABLET TRIBENZOR MG TABLET TRIBENZOR MG TABLET TRIBENZOR MG TABLET TRIBENZOR MG TABLET TWYNSTA 40-5 MG TABLET TWYNSTA MG TABLET TWYNSTA 80-5 MG TABLET TWYNSTA MG TABLET ZEBETA 5 MG TABLET ZEBETA 10 MG TABLET ZIAC MG TABLET ZIAC MG TABLET ZIAC MG TABLET Step 3 (history of greater than or equal to ( ) 90 days of therapy with ranolazine) Look back timeframe: 120 days For the list of drug names and s that pertain to this step, see the Drugs Requiring Prior Authorization table in the Supporting Tables section. Note: Click the hyperlink to navigate directly to the table. Step 4 (diagnosis of clinically-significant hepatic impairment) Required diagnosis: 1 ICD HEPATITIS A WITH COMA 0701 HEPATITIS A W/O COMA HPT B ACTE COMA WO DLTA April 3, 2012 Copyright 2012 Health Information Designs, LLC 11

12 Step 4 (diagnosis of clinically-significant hepatic impairment) Required diagnosis: 1 ICD HPT B ACTE COMA W DLTA HPT B CHRN COMA WO DLTA HPT B CHRN COMA W DLTA HPT B ACTE WO CM WO DLTA HPT B ACTE WO CM W DLTA HPT B CHRN WO CM WO DLTA HPT B CHRN WO CM W DLTA ACUTE HEPATITIS C WITH HEPATIC COMA HPT DLT WO B W HPT COMA HPT E W HEPAT COMA CHRNC HPT C W HEPAT COMA OTH VRL HEPAT W HPT COMA ACUTE HEPATITIS C WITHOUT MENTION OF HEPATIC COMA HPT DLT WO B WO HPT COMA HPT E WO HEPAT COMA CHRNC HPT C WO HPAT COMA OTH VRL HPAT WO HPT COMA 0706 VIRAL HEPAT NOS W COMA UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITH HEPATIC COMA 0709 VIRAL HEPAT NOS W/O COMA 5710 ALCOHOLIC FATTY LIVER 5711 AC ALCOHOLIC HEPATITIS 5712 ALCOHOL CIRRHOSIS LIVER 5713 ALCOHOL LIVER DAMAGE NOS CHRONIC HEPATITIS NOS CHR PERSISTENT HEPATITIS AUTOIMMUNE HEPATITIS CHRONIC HEPATITIS NEC 5715 CIRRHOSIS OF LIVER NOS 5716 BILIARY CIRRHOSIS 5718 CHRONIC LIVER DIS NEC 5719 CHRONIC LIVER DIS NOS 5720 ABSCESS OF LIVER 5721 PORTAL PYEMIA April 3, 2012 Copyright 2012 Health Information Designs, LLC 12

13 Step 4 (diagnosis of clinically-significant hepatic impairment) Required diagnosis: 1 ICD HEPATIC ENCEPHALOPATHY 5723 PORTAL HYPERTENSION 5724 HEPATORENAL SYNDROME 5728 OTH SEQUELA, CHR LIV DIS 5730 CHR PASSIV CONGEST LIVER 5731 HEPATITIS IN VIRAL DIS 5732 HEPATITIS IN OTH INF DIS 5733 HEPATITIS NOS 5734 HEPATIC INFARCTION 5738 LIVER DISORDERS NEC 5739 LIVER DISORDER NOS Step 5 (history of a drug that is contraindicated with ranolazine) Look back timeframe: 30 days BIAXIN 125 MG/5 ML SUSPENSION BIAXIN 250 MG TABLET BIAXIN 250 MG/5 ML SUSPENSION BIAXIN 500 MG TABLET BIAXIN XL 500 MG TABLET CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE 100 MG/5 ML SUSP CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE XR 200 MG TABLET CARBAMAZEPINE XR 400 MG TABLET CARBATROL ER 100 MG CAPSULE CARBATROL ER 200 MG CAPSULE CARBATROL ER 300 MG CAPSULE CLARITHROMYCIN 125 MG/5 ML SUS CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN 250 MG/5 ML SUS CLARITHROMYCIN 500 MG TABLET CLARITHROMYCIN ER 500 MG TAB CRIXIVAN 100 MG CAPSULE April 3, 2012 Copyright 2012 Health Information Designs, LLC 13

14 Step 5 (history of a drug that is contraindicated with ranolazine) Look back timeframe: 30 days CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE EPITOL 200 MG TABLET EQUETRO 100 MG CAPSULE EQUETRO 200 MG CAPSULE EQUETRO 300 MG CAPSULE INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET ISONARIF CAPSULE ITRACONAZOLE 100 MG CAPSULE KALETRA MG TABLET KALETRA MG TABLET KALETRA /5 ML ORAL SOLU KETOCONAZOLE 200 MG TABLET LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET MYCOBUTIN 150 MG CAPSULE NEFAZODONE HCL 50 MG TABLET NEFAZODONE HCL 100 MG TABLET NEFAZODONE HCL 150 MG TABLET NEFAZODONE HCL 200 MG TABLET NEFAZODONE HCL 250 MG TABLET NORVIR 80 MG/ML SOLUTION NORVIR 100 MG SOFTGEL CAP NORVIR 100 MG TABLET PHENOBARBITAL 20 MG/5 ML ELIX PHENOBARBITAL 15 MG TABLET PHENOBARBITAL 16.2 MG TABLET 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 PREVPAC PATIENT PACK April 3, 2012 Copyright 2012 Health Information Designs, LLC 14

15 Step 5 (history of a drug that is contraindicated with ranolazine) Look back timeframe: 30 days PRIFTIN 150 MG TABLET REYATAZ 100 MG CAPSULE REYATAZ 150 MG CAPSULE REYATAZ 200 MG CAPSULE REYATAZ 300 MG CAPSULE RIFADIN 150 MG CAPSULE RIFADIN 300 MG CAPSULE RIFADIN IV 600 MG VIAL RIFAMATE CAPSULE RIFAMPIN 150 MG CAPSULE RIFAMPIN 300 MG CAPSULE RIFATER TABLET SPORANOX 10 MG/ML SOLUTION SPORANOX 100 MG CAPSULE TEGRETOL 100 MG TABLET CHEW TEGRETOL 100 MG/5 ML SUSP TEGRETOL 200 MG TABLET TEGRETOL XR 100 MG TABLET TEGRETOL XR 200 MG TABLET TEGRETOL XR 400 MG TABLET VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET April 3, 2012 Copyright 2012 Health Information Designs, LLC 15

16 Clinical Edit Criteria References 1. [package insert]. Foster City, CA: Gilead Sciences, Inc. December Available at Accessed on March 7, MICROMEDEX Health Services. DRUGDEX evaluations: drug evaluation. Available at: Accessed on February 28, Lexi-Comp Drug Information Handbook. drug evaluation. Available at: Accessed on February 28, April 3, 2012 Copyright 2012 Health Information Designs, LLC 16

17 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 04/03/2012 Initial publication and posting to website April 3, 2012 Copyright 2012 Health Information Designs, LLC 17