Topical Immunomodulators

Transcription

1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Topical Immunomodulators Clinical Edit Information Included in this Document Topical Immunomodulators Elidel and Protopic 0.03% 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 Topical Immunomodulators Protopic 0.1% 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 te: Click the hyperlink to navigate directly to that section. April 24, 2014 Copyright Health Information Designs, LLC 1

2 Texas Prior Authorization Program Clinical Edits Topical Immunomodulators Revision tes In the Clinical Edit Criteria Logic section for Elidel and Protopic 0.03%, revised question #10 decision steps to if yes, approve and if no, deny. In the Clinical Edit Criteria Logic section for Protopic 0.1%, revised question #9 decision steps to if yes, approve and if no, deny. April 24, 2014 Copyright Health Information Designs, LLC 2

3 Topical Immunomodulators Elidel and Protopic 0.03% Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization ELIDEL 1% CREAM PROTOPIC 0.03% OINTMENT April 24, 2014 Copyright Health Information Designs, LLC 3

4 Topical Immunomodulators Elidel and Protopic 0.03% Clinical Edit Criteria Logic 1. Is the client less than or equal to ( ) 2 years of age? [ ] (Go to #2) [ ] (Go to #3) 2. history of a topical steroid or nystatin/triamcinolone prescription in the last 730 days? [ ] (Go to #3) [ ] (Deny) 3. diagnosis of atopic dermatitis in the last 730 days? [ ] (Go to #4) [ ] (Deny) 4. history of a topical steroid or nystatin/triamcinolone prescription in the last 90 days? [ ] (Go to #6) [ ] (Go to #5) 5. history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? [ ] (Go to #6) [ ] (Deny) 6. diagnosis of HIV or immune system disorder in the last 730 days? [ ] (Deny) [ ] (Go to #7) 7. history of HIV drugs or immunosuppressants in the last 730 days? [ ] (Deny) [ ] (Go to #8) 8. history of antineoplastic agents in the last 730 days? [ ] (Deny) [ ] (Go to #9) 9. history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? [ ] (Go to #10) [ ] (Approve 6 weeks) April 24, 2014 Copyright Health Information Designs, LLC 4

5 10. history of a prior pimecrolimus/tacrolimus prescription less than or equal to ( ) 84 days in the last 112 days? [ ] (Approve 6 weeks) [ ] (Deny) April 24, 2014 Copyright Health Information Designs, LLC 5

6 Topical Immunomodulators Elidel and Protopic 0.03% Clinical Edit Criteria Logic Diagram Step 1 Step 2 Is the client 2 years of age? history of a topical steroid or nystatin/triamcinolone prescription in the last 730 days? Deny Request Step 3 Step 4 Step 5 diagnosis of atopic dermatitis in the last 730 days? history of a topical steroid or nystatin/triamcinolone prescription in the last 90 days? history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? Deny Request Step 6 Step 7 Deny Request diagnosis of HIV or immune system disorder in the last 730 days? history of HIV drugs or immunosuppressants in the last 730 days? Deny Request Step 10 Step 9 Step 8 history of a prior pimecrolimus/tacrolimus prescription 84 days in the last 112 days? history of a prior pimecrolimus/tacrolimus prescription in the 365 days? history of antineoplastic agents in the last 730 days? Deny Request Approve Request (6 weeks) Approve Request (6 weeks) April 24, 2014 Copyright Health Information Designs, LLC 6

7 Topical Immunomodulators Elidel and Protopic 0.03% Clinical Edit Criteria Supporting Tables Step 2 (history of a topical steroid or nystatin/triamcinolone prescription) Topical Steroids and Nystatin/Triamcinolone Drugs ALCLOMETASONE DIPRO 0.05% CRM ALCLOMETASONE DIPR 0.05% OINT AMCINONIDE 0.1% CREAM AMCINONIDE 0.1% LOTION AMCINONIDE 0.1% OINTMENT ANUSOL-HC 2.5% CREAM APEXICON 0.05% OINTMENT APEXICON E 0.05% CREAM BETAMETHASONE DP 0.05% CRM BETAMETHASONE DP 0.05% LOT BETAMETHASONE DP 0.05% OINT BETAMETHASONE DP AUG 0.05% CRM BETAMETHASONE DP AUG 0.05% GEL BETAMETHASONE DP AUG 0.05% LOT BETAMETHASONE DP AUG 0.05% OIN BETAMETHASONE VA 0.1% CREAM BETAMETHASONE VA 0.1% LOTION BETAMETHASONE VALER 0.1% OINTM BETA-VAL 0.1% LOTION CLOBETASOL 0.05% CREAM CLOBETASOL 0.05% GEL CLOBETASOL 0.05% OINTMENT CLOBETASOL 0.05% SOLUTION CLOBETASOL EMOLLIENT 0.05% CRM CLOBETASOL PROP 0.05% FOAM CLOBEX 0.05% SPRAY CLOBEX 0.05% TOPICAL LOTION CLODERM 0.1% CREAM CORDRAN 4 MCG/SQ CM TAPE April 24, 2014 Copyright Health Information Designs, LLC 7

8 Step 2 (history of a topical steroid or nystatin/triamcinolone prescription) Topical Steroids and Nystatin/Triamcinolone Drugs CORMAX 0.05% SOLUTION CORTISPORIN OINTMENT CUTIVATE 0.05% LOTION DERMA-SMOOTHE-FS BODY OIL DERMA-SMOOTHE-FS SCALP OIL DERMATOP 0.1% CREAM DERMATOP 0.1% OINTMENT DESONIDE 0.05% CREAM DESONIDE 0.05% LOTION DESONIDE 0.05% OINTMENT DESOXIMETASONE 0.05% CREAM DESOXIMETASONE 0.25% CREAM DESOXIMETASONE 0.05% GEL DESOXIMETASONE 0.25% OINTMENT DIFLORASONE 0.05% CREAM DIFLORASONE 0.05% OINTMENT DIPROLENE 0.05% LOTION DIPROLENE 0.05% OINTMENT DIPROLENE AF 0.05% CREAM ELOCON 0.1% CREAM ELOCON 0.1% LOTION ELOCON 0.1% OINTMENT FLUOCINOLONE 0.01% CREAM FLUOCINOLONE 0.025% CREAM FLUOCINONIDE 0.05% CREAM FLUOCINONIDE 0.05% GEL FLUOCINOLONE 0.025% OINT FLUOCINONIDE 0.05% OINTMENT FLUOCINOLONE 0.01% SOLUTION FLUOCINONIDE 0.05% SOLUTION FLUOCINONIDE-E 0.05% CREAM FLUOCINONIDE-EMOL 0.05% CREAM FLUTICASONE PROP 0.05% CREAM FLUTICASONE PROP 0.005% OINT April 24, 2014 Copyright Health Information Designs, LLC 8

9 Step 2 (history of a topical steroid or nystatin/triamcinolone prescription) Topical Steroids and Nystatin/Triamcinolone Drugs HALOBETASOL PROP 0.05% CREAM HALOBETASOL PROP 0.05% OINTMNT HALOG 0.1% CREAM HALOG 0.1% OINTMENT HYDRO SKIN 1% LOTION HYDROCORTISONE 0.5% CREAM HYDROCORTISONE 1% CREAM HYDROCORTISONE 1% CREAM HYDROCORTISONE 2.5% CREAM HYDROCORTISONE 1% LOTION HYDROCORTISONE 2.5% LOTION HYDROCORTISONE 0.5% OINTMENT HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 2.5% OINTMENT HYDROCORTISONE 0.1% SOLN HYDROCORTISONE ACETATE 2% GEL HYDROCORTISONE BUTY 0.1% CREAM HYDROCORTISONE BUTYR 0.1% OINT HYDROCORTISONE VAL 0.2% CREAM HYDROCORTISONE VAL 0.2% OINTMT ITCH-X HC 1% LOTION LOKARA 0.05% LOTION MEDI-CORTISONE 1% CREAM MOMETASONE FUROATE 0.1% CREAM MOMETASONE FUROATE 0.1% OINT MOMETASONE FUROATE 0.1% SOLN NUZON GEL OLUX 0.05% FOAM OLUX-E 0.05% FOAM PREDNICARBATE 0.1% CREAM PREDNICARBATE 0.1% OINTMENT PROCTOCREAM-HC 2.5% CREAM PROCTOSOL-HC 2.5% CREAM PROCTOZONE-HC 2.5% CREAM April 24, 2014 Copyright Health Information Designs, LLC 9

10 Step 2 (history of a topical steroid or nystatin/triamcinolone prescription) Topical Steroids and Nystatin/Triamcinolone Drugs TOPICORT 0.05% GEL TOPICORT 0.25% CREAM TOPICORT 0.25% OINTMENT TOPICORT LP 0.05% CREAM TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE 0.5% CREAM TRIAMCINOLONE 0.025% LOTION TRIAMCINOLONE 0.1% LOTION TRIAMCINOLONE 0.025% OINT TRIAMCINOLONE 0.1% OINTMENT TRIAMCINOLONE 0.5% OINTMENT TRIANEX 0.05% OINTMENT ULTRAVATE 0.05% CREAM VANOS 0.1% CREAM VERDESO 0.05% FOAM WESTCORT 0.2% OINTMENT Step 3 (diagnosis of atopic dermatitis) Required diagnosis: 1 Atopic Dermatitis Diagnoses ICD-9 Code Description 691 ATOPIC DERMATITIS AND RELATED CONDITIONS 6910 DIAPER OR NAPKIN RASH 6918 OTHER ATOPIC DERMATITIS April 24, 2014 Copyright Health Information Designs, LLC 10

11 Step 4 (history of topical steroid or nystatin/triamcinolone prescription) Look back timeframe: 90 days For the list of topical steroids and nystatin/triamcinolone drugs that pertain to this step, see the Topical Steroids and Nystatin/Triamcinolone Drugs table in this Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 5 (history of a prior pimecrolimus/tacrolimus prescription) Look back timeframe: 365 days Pimecrolimus/Tacrolimus Drugs ELIDEL 1% CREAM PROTOPIC 0.03% OINTMENT PROTOPIC 0.1% OINTMENT Step 6 (diagnosis of HIV or immune system disorder) Required diagnosis: 1 HIV and Immune System Disorder Diagnoses ICD-9 Code Description 042 HUMAN IMMUNO VIRUS DIS 279 DISORDERS INVOLVING THE IMMUNE MECHANISM 2790 DEFICIENCY OF HUMORAL IMMUNITY HYPOGAMMAGLOBULINEM NOS SELECTIVE IGA IMMUNODEF SELECTIVE IGM IMMUNODEF SELECTIVE IG DEFIC NEC CONG HYPOGAMMAGLOBULINEM IMMUNODEFIC W HYPER-IGM COMMON VARIABL IMMUNODEF HUMORAL IMMUNITY DEF NEC 2791 DEFICIENCY OF CELL-MEDIATED IMMUNITY IMMUNDEF T-CELL DEF NOS DIGEORGE'S SYNDROME WISKOTT-ALDRICH SYNDROME NEZELOF'S SYNDROME April 24, 2014 Copyright Health Information Designs, LLC 11

12 Step 6 (diagnosis of HIV or immune system disorder) Required diagnosis: 1 HIV and Immune System Disorder Diagnoses ICD-9 Code Description DEFIC CELL IMMUNITY NOS 2792 COMBINED IMMUNITY DEFIC 2793 IMMUNITY DEFICIENCY NOS 2794 AUTOIMMUNE DISEASE NEC 2795 GRAFT-VERSUS-HOST DISEASE GRAFT-VERSUS-HOST DISEASE, UNSPECIFIED ACUTE GRAFT-VERSUS-HOST DISEASE CHRONIC GRAFT-VERSUS-HOST DISEASE ACUTE ON CHRONIC GRAFT-VERSUS-HOST DISEASE 2798 IMMUNE MECHANISM DIS NEC 2799 IMMUNE MECHANISM DIS NOS Step 7 (history of HIV drugs or immunosuppressants) HIV Drugs and Immunosuppressants APTIVUS 250 MG CAPSULE ATRIPLA TABLET AZATHIOPRINE 50 MG TABLET CELLCEPT 200 MG/ML ORAL SUSP CELLCEPT 250 MG CAPSULE CELLCEPT 500 MG TABLET COMBIVIR TABLET COMPLERA TABLET COPAXONE 20 MG INJECTION KIT CRIXIVAN 100 MG CAPSULE CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE 50 MG SOFTGEL CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE 100 MG/ML SOLN April 24, 2014 Copyright Health Information Designs, LLC 12

13 Step 7 (history of HIV drugs or immunosuppressants) HIV Drugs and Immunosuppressants CYCLOSPORINE MODIFIED 25 MG CYCLOSPORINE MODIFIED 100 MG DIDANOSINE DR 125 MG CAPSULE DIDANOSINE DR 200 MG CAPSULE DIDANOSINE DR 250 MG CAPSULE DIDANOSINE DR 400 MG CAPSULE EDURANT 25 MG TABLET EMTRIVA 200 MG CAPSULE EPIVIR 10 MG/ML ORAL SOLN EPIVIR 150 MG TABLET EPIVIR 300 MG TABLET EPIVIR HBV 25 MG/5 ML SOLN EPIVIR HBV 100 MG TABLET EPZICOM TABLET FUZEON CONVENIENCE KIT GENGRAF 25 MG CAPSULE GENGRAF 100 MG CAPSULE GENGRAF 100 MG/ML SOLUTION IMURAN 50 MG TABLET INTELENCE 100 MG TABLET INTELENCE 200 MG TABLET INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET ISENTRESS 400 MG TABLET KALETRA MG TABLET KALETRA MG TABLET KALETRA /5 ML ORAL SOLU LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET MYCOPHENOLATE 250 MG CAPSULE MYCOPHENOLATE 500 MG TABLET MYFORTIC 180 MG TABLET MYFORTIC 360 MG TABLET NEORAL 25 MG GELATIN CAPSULE April 24, 2014 Copyright Health Information Designs, LLC 13

14 Step 7 (history of HIV drugs or immunosuppressants) HIV Drugs and Immunosuppressants NEORAL 100 MG GELATN CAPSULE NORVIR 100 MG SOFTGEL CAP NORVIR 80 MG/ML SOLUTION NORVIR 100 MG TABLET PREZISTA 75 MG TABLET PREZISTA 150 MG TABLET PREZISTA 400 MG TABLET PREZISTA 600 MG TABLET PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE RAPAMUNE 1 MG/ML ORAL SOLN RAPAMUNE 1 MG TABLET RAPAMUNE 2 MG TABLET RESCRIPTOR 100 MG TABLET RESCRIPTOR 200 MG TABLET RETROVIR 100 MG CAPSULE RETROVIR 10 MG/ML SYRUP RETROVIR 300 MG TABLET RETROVIR 10 MG/ML VIAL RETROVIR IV INFUSION VIAL REYATAZ 100 MG CAPSULE REYATAZ 150 MG CAPSULE REYATAZ 200 MG CAPSULE REYATAZ 300 MG CAPSULE SANDIMMUNE 25 MG CAPSULE SANDIMMUNE 100 MG CAPSULE SANDIMMUNE 100 MG/ML SOLN SELZENTRY 150 MG TABLET SELZENTRY 300 MG TABLET STAVUDINE 15 MG CAPSULE STAVUDINE 20 MG CAPSULE STAVUDINE 30 MG CAPSULE STAVUDINE 40 MG CAPSULE April 24, 2014 Copyright Health Information Designs, LLC 14

15 Step 7 (history of HIV drugs or immunosuppressants) HIV Drugs and Immunosuppressants SUSTIVA 50 MG CAPSULE SUSTIVA 200 MG CAPSULE SUSTIVA 600 MG TABLET TACROLIMUS 0.5 MG CAPSULE TACROLIMUS 1 MG CAPSULE TACROLIMUS 5 MG CAPSULE THALOMID 50 MG CAPSULE THALOMID 100 MG CAPSULE THALOMID 150 MG CAPSULE THALOMID 200 MG CAPSULE TRIZIVIR TABLET TRUVADA 200 MG-300 MG TABLET VIDEX 2 GM PEDIATRIC SOLN VIDEX 4 GM PEDIATRIC SOLN VIDEX EC 125 MG CAPSULE VIDEX EC 200 MG CAPSULE VIDEX EC 250 MG CAPSULE VIDEX EC 400 MG CAPSULE VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VIRAMUNE 50 MG/5 ML SUSP VIRAMUNE 200 MG TABLET VIRAMUNE XR 400 MG TABLET VIREAD 300 MG TABLET ZERIT 1 MG/ML SOLUTION ZERIT 15 MG CAPSULE ZERIT 20 MG CAPSULE ZERIT 30 MG CAPSULE ZERIT 40 MG CAPSULE ZIAGEN 20 MG/ML SOLUTION ZIAGEN 300 MG TABLET ZIDOVUDINE 100 MG CAPSULE ZIDOVUDINE 50 MG/5 ML SYRUP ZIDOVUDINE 300 MG TABLET April 24, 2014 Copyright Health Information Designs, LLC 15

16 Step 8 (history of antineoplastic agents) Antineoplastic Agents ALKERAN 2 MG TABLET ANASTROZOLE 1 MG TABLET ARIMIDEX 1 MG TABLET AROMASIN 25 MG TABLET AVODART 0.5 MG SOFTGEL AZELEX 20% CREAM BICALUTAMIDE 50 MG TABLET CARAC CREAM CASODEX 50 MG TABLET CEENU 10 MG CAPSULE CEENU 40 MG CAPSULE CEENU 100 MG CAPSULE COSMEGEN 0.5 MG VIAL CYCLOPHOSPHAMIDE 25 MG TAB CYCLOPHOSPHAMIDE 50 MG TABLET CYTARABINE 20 MG/ML VIAL CYTARABINE 20 MG/ML VIAL CYTARABINE 20 MG/ML VIAL CYTARABINE 100 MG VIAL CYTARABINE 100 MG/ML VIAL CYTARABINE 500 MG VIAL CYTARABINE 1 GM VIAL CYTARABINE 2 GM VIAL DROXIA 200 MG CAPSULE DROXIA 300 MG CAPSULE DROXIA 400 MG CAPSULE EFUDEX 5% CREAM EFUDEX 5% SOLUTION EMCYT 140 MG CAPSULE ETOPOSIDE 50 MG CAPSULE ETOPOSIDE 100 MG/5 ML VIAL ETOPOSIDE 500 MG/25 ML VIAL ETOPOSIDE 1,000 MG/50 ML VIAL EVISTA 60 MG TABLET April 24, 2014 Copyright Health Information Designs, LLC 16

17 Step 8 (history of antineoplastic agents) Antineoplastic Agents FARESTON 60 MG TABLET FEMARA 2.5 MG TABLET FINACEA 15% GEL FINASTERIDE 5 MG TABLET FLUOROPLEX 1% CREAM FLUOROURACIL 5% CREAM FLUOROURACIL 2% TOPICAL SOLN FLUOROURACIL 5% TOP SOLUTION FLUTAMIDE 125 MG CAPSULE GLEEVEC 100 MG TABLET GLEEVEC 400 MG TABLET HEXALEN 50 MG CAPSULE HYCAMTIN 0.25 MG CAPSULE HYCAMTIN 1 MG CAPSULE HYDROXYUREA 500 MG CAPSULE IRESSA 250 MG TABLET JALYN MG CAPSULE LETROZOLE 2.5 MG TABLET LEUKERAN 2 MG TABLET LYSODREN 500 MG TABLET MATULANE 50 MG CAPSULE MEGACE 40 MG/ML ORAL SUSP MEGACE ES 625 MG/5 ML SUSP MEGESTROL 20 MG TABLET MEGESTROL 40 MG TABLET MEGESTROL ACET 40 MG/ML SUSP MERCAPTOPURINE 50 MG TABLET METHOTREXATE 2.5 MG TABLET METHOTREXATE 25 MG/ML VIAL METHOTREXATE 25 MG/ML VIAL MITOMYCIN 5 MG VIAL MITOMYCIN 20 MG VIAL MITOMYCIN 40 MG VIAL MITOXANTRONE 20 MG/10 ML VIAL April 24, 2014 Copyright Health Information Designs, LLC 17

18 Step 8 (history of antineoplastic agents) Antineoplastic Agents MITOXANTRONE 25 MG/12.5 ML VL MITOXANTRONE 30 MG/15 ML VIAL MYLERAN 2 MG TABLET NEXAVAR 200 MG TABLET NILANDRON 150 MG TABLET NOVANTRONE 2 MG/ML VIAL OFORTA 10 MG TABLET ONCASPAR 750 UNIT/ML VIAL PROSCAR 5 MG TABLET PURINETHOL 50 MG TABLET RHEUMATREX 2.5 MG TABLET SPRYCEL 20 MG TABLET SPRYCEL 50 MG TABLET SPRYCEL 70 MG TABLET SUTENT 12.5 MG CAPSULE SUTENT 25 MG CAPSULE SUTENT 50 MG CAPSULE TABLOID 40 MG TABLET TAMOXIFEN 10 MG TABLET TAMOXIFEN 20 MG TABLET TARCEVA 25 MG TABLET TARCEVA 100 MG TABLET TARCEVA 150 MG TABLET TARGRETIN 1% GEL TARGRETIN 75 MG SOFTGEL TASIGNA 150 MG CAPSULE TASIGNA 200 MG CAPSULE TEMODAR 5 MG CAPSULE TEMODAR 20 MG CAPSULE TEMODAR 100 MG CAPSULE TEMODAR 140 MG CAPSULE TEMODAR 180 MG CAPSULE TEMODAR 250 MG CAPSULE TREXALL 5 MG TABLET April 24, 2014 Copyright Health Information Designs, LLC 18

19 Step 8 (history of antineoplastic agents) Antineoplastic Agents TREXALL 7.5 MG TABLET TREXALL 10 MG TABLET TREXALL 15 MG TABLET TYKERB 250 MG TABLET VINBLASTINE 1 MG/ML VIAL VINBLASTINE SULF 10 MG VIAL VINCRISTINE 1 MG/ML VIAL VINCRISTINE 2 MG/2 ML VIAL VOTRIENT 200 MG TABLET XELODA 150 MG TABLET XELODA 500 MG TABLET ZOLINZA 100 MG CAPSULE Step 9 (history of a prior pimecrolimus/tacrolimus prescription) Look back timeframe: 365 days For the list of pimecrolimus/tacrolimus prescriptions that pertain to this step, see the Pimecrolimus/Tacrolimus Drugs table in this Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 10 (history of a prior pimecrolimus/tacrolimus prescription 84 days) Look back timeframe: 112 days For the list of pimecrolimus/tacrolimus prescriptions that pertain to this step, see the Pimecrolimus/Tacrolimus Drugs table in this Supporting Tables section. te: Click the hyperlink to navigate directly to the table. April 24, 2014 Copyright Health Information Designs, LLC 19

20 Texas Prior Authorization Program Clinical Edits Protopic 0.1% Topical Immunomodulators Protopic 0.1% Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization PROTOPIC 0.1% OINTMENT April 24, 2014 Copyright Health Information Designs, LLC 20

21 Texas Prior Authorization Program Clinical Edits Protopic 0.1% Topical Immunomodulators Protopic 0.1% Clinical Edit Criteria Logic 1. Is the client less than (<) 16 years of age? [ ] (Deny) [ ] (Go to #2) 2. diagnosis of atopic dermatitis in the last 730 days? [ ] (Go to #3) [ ] (Deny) 3. history of a topical steroid or nystatin/triamcinolone prescription in the last 90 days? [ ] (Go to #5) [ ] (Go to #4) 4. history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? [ ] (Go to #5) [ ] (Deny) 5. Has the client had a diagnosis of HIV or immune system disorder in the last 730 days? [ ] (Deny) [ ] (Go to #6) 6. history of HIV drugs or immunosuppressants in the last 730 days? [ ] (Deny) [ ] (Go to #7) 7. history of antineoplastic agents in the last 730 days? [ ] (Deny) [ ] (Go to #8) 8. history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? [ ] (Go to #9) [ ] (Approve 6 weeks) 9. history of a prior pimecrolimus/tacrolimus prescription less than or equal to ( ) 84 days in the last 112 days? [ ] (Approve 6 weeks) [ ] (Deny) April 24, 2014 Copyright Health Information Designs, LLC 21

22 Texas Prior Authorization Program Clinical Edits Protopic 0.1% Topical Immunomodulators Protopic 0.1% Clinical Edit Criteria Logic Diagram Step 1 Is the client < 16 years of age? Deny Request Step 2 Step 3 Step 4 diagnosis of atopic dermatitis in the last 730 days? history of a topical steroid or nystatin/triamcinolone prescription in the last 90 days? history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? Deny Request Step 5 Step 6 Deny Request Has the client had a diagnosis of HIV or immune system disorder in the last 730 days? history of HIV drugs or immunosuppressants in the last 730 days? Deny Request Step 9 Step 8 Step 7 history of a prior pimecrolimus/tacrolimus prescription 84 days in the last 112 days? history of a prior pimecrolimus/tacrolimus prescription in the last 365 days? history of antineoplastic agents in the last 730 days? Deny Request Approve Request (6 weeks) Approve Request (6 weeks) April 24, 2014 Copyright Health Information Designs, LLC 22

23 Texas Prior Authorization Program Clinical Edits Protopic 0.1% Topical Immunomodulators Protopic 0.1% Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of atopic dermatitis) Required diagnosis: 1 For the list of atopic dermatitis diagnoses that pertain to this step, see the Atopic Dermatitis Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 3 (history of a topical steroid or nystatin/triamcinolone) Look back timeframe: 90 days For the list of topical steroids and nystatin/triamcinolone drugs that pertain to this step, see the Topical Steroids and Nystatin/Triamcinolone Drugs table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 4 (history of a pimecrolimus/tacrolimus prescription) Look back timeframe: 365 days For the list of pimecrolimus/tacrolimus prescriptions that pertain to this step, see the Pimecrolimus/Tacrolimus Drugs table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 5 (diagnosis of HIV or immune system disorder) Required diagnosis: 1 For the list of HID and immune system disorder diagnoses that pertain to this step, see the HIV and Immune System Disorder Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. April 24, 2014 Copyright Health Information Designs, LLC 23

24 Texas Prior Authorization Program Clinical Edits Protopic 0.1% Step 6 (history of HIV drugs or immunosuppressants) For the list of HIV drugs and immunosuppressants that pertain to this step, see the HIV Drugs and Immunosuppressants table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 7 (history of an antineoplastic agent) For the list of antineoplastic agents that pertain to this step, see the Antineoplastic Agents table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 8 (history of a pimecrolimus/tacrolimus prescription) Look back timeframe: 365 days For the list of pimecrolimus/tacrolimus prescriptions that pertain to this step, see the Pimecrolimus/Tacrolimus Drugs table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 9 (history of a pimecrolimus/tacrolimus prescription 84 days) Look back timeframe: 112 days For the list of pimecrolimus/tacrolimus prescriptions that pertain to this step, see the Pimecrolimus/Tacrolimus Drugs table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. April 24, 2014 Copyright Health Information Designs, LLC 24

25 Texas Prior Authorization Program Clinical Edits Topical Immunomodulators Topical Immunomodulators Clinical Edit Criteria References 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier / Gold Standard, Inc.; Available at Accessed on May 20, ICD-9-CM Diagnosis Codes, Volume Available at Accessed on May 20, ICD-10-CM Diagnosis Codes, Volume Available at Accessed on May 20, Protopic prescribing information. Astellas Pharma US, Inc. rthbrook, IL. May Elidel prescribing information. Valeant Pharmaceuticals rth America LLC. Bridgewater, NJ. March April 24, 2014 Copyright Health Information Designs, LLC 25

26 Texas Prior Authorization Program Clinical Edits Topical Immunomodulators 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 01/31/2011 Initial publication and posting to website 04/10/2012 Added a new section to specify the drugs requiring prior authorization for each form of topical immunomodulators Revised age check (step 1) in criteria logic and logic diagram for Elidel and Protopic 0.03% from less than 3 (<3) to less than or equal to ( ) 2 years of age In the Clinical Edit Supporting Tables section for Elidel and Protopic 0.03%, revised tables to specify the drug names and s pertinent to steps 2, 4, 5, 7, 8, 9, and 10 of the logic diagram In the Clinical Edit Supporting Tables section for Elidel and Protopic 0.03%, revised tables to specify the diagnosis codes pertinent to steps 3 and 6 of the logic diagram In the Clinical Edit Supporting Tables section for Protopic 0.1%, revised tables to specify the diagnosis codes pertinent to steps 2 and 5 of the logic diagram In the Clinical Edit Supporting Tables section for Protopic 0.1%, revised tables to specify the drug names and s pertinent to steps 3, 4, 6, 7, 8, and 9 of the logic diagram 4/24/2014 In the Clinical Edit Criteria Logic section for Elidel and Protopic 0.03%, revised question #10 decision steps to if yes, approve and if no, deny. In the Clinical Edit Criteria Logic section for Protopic 0.1%, revised question #9 decision steps to if yes, approve and if no, deny. April 24, 2014 Copyright Health Information Designs, LLC 26