Texas Standard Prior Authorization Form Addendum
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1 Texas Standard Prior Authorization Form Addendum Molina Healthcare of Texas Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA Regulations. Complete / Review information, sign, and date. Fax signed forms to Molina Pharmacy Prior Authorization Department at Please contact Molina Pharmacy Prior Authorization Department at with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Antipsychotics (Medicaid). Drug ame (select from list of drugs shown) Antipsychotics - First Generation Antipsychotics 2 nd Generation Patient ame: Patient ID: Patient DOB: Amitriptyline/Perphenazine Abilify Olanzapine Ziprasidone Physician ame: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Chlorpromazine Abilify Maintena ER Olanzapine/Fluoxetine Zyprexa Fluphenazine Aristada ER Quetiapine Zyprexa Relprevv Haloperidol Clozapine Rexulti Zyprexa Zydis Loxapine Clozaril Risperdal Aripiprazole Loxitane Fanapt Risperdal Consta Vraylar Moban Fazaclo Risperidone Orap Geodon Saphris Perphenazine Invega ER Seroquel Thioridazine Invega Sustenna Seroquel XR Thiothixene Invega Trinza Symbyax Trifluoperazine Latuda Versacloz Patient Information Prescribing Physician Diagnosis: ICD Code: Directions for administration: Please circle the appropriate answer for each question. 1. Is the incoming claim for a first generation antipsychotic? If the answer to this question is yes, go to question 5. If the answer to this question is no, go to question 2.
2 2. Is the patient less than (<) 3 years of age? If the answer to this question is yes, denied. If the answer to this question is no, go to question Is the patient greater than (>) 5 years of age? If the answer to this question is yes, go to question 5. If the answer to this question is no, go to question Is the incoming request for aripiprazole or risperidone? If the answer to this question is yes, go to question 5. If the answer to this question is no, deny. 5. Does the patient have a diagnosis of insomnia in the last 365 days? If the answer to this question is yes, go to question 8. If the answer to this question is no, go to question Does the patient have a diagnosis of depression or major depressive disorder (MDD) in the last 365 days? If the answer to this question is yes, go to question 7. If the answer to this question is no, go to question Does the patient have 1 claim for an antidepressant agent in the last 60 days? If the answer to this question is yes, go to question 9. If the answer to this question is no, go to question Does the patient have a diagnosis included in Table A or B in the last 730 days? If the answer to this question is yes, go to question 9. If the answer to this question is no, deny. 9. Does the patient have 2 or more active claims for different antipsychotic agents in the last 180 days (excluding the incoming request)? If the answer to this question is yes, go to question 10. If the answer to this question is no, go to question Does the patient have 2 or more active claims for different antipsychotic agents in the last 30 days with (excluding the incoming request)? If the answer to this question is yes, deny. If the answer to this question is no, go to question Is this request for a non-preferred drug? The Texas Medicaid Preferred Drug List can be found at txvendordrug.com If the answer to this question is yes, go to question 12. If the answer to this question is no, approve for 365 days. 12. Has the patient been stable on 1 non-preferred agent for 30-days in the past 180 days? If the answer to this question is yes, approve for 365 days. If the answer to this question is no, go to question Has the patient failed a 14-day treatment with at least 1 preferred agent(s) within the past 180 days? If the answer to this question is yes, approve for 365 days. If the answer to this question is no, go to question Is there a documented allergy or contraindication to preferred agents in this class? If yes, please list which drug, dates tried, and describe treatment failure, contraindication or allergy. If no, deny.
3 Table A ICD-10 Code Description SIMPLE TPE SCHIZOPHREIA, USPECIFIED SIMPLE TPE SCHIZOPHREIA, SUBCHROIC SIMPLE TPE SCHIZOPHREIA, CHROIC SIMPLE TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO SIMPLE TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO SIMPLE TPE SCHIZOPHREIA, I REMISSIO DISORGAIZED TPE SCHIZOPHREIA, USPECIFIED DISORGAIZED TPE SCHIZOPHREIA, SUBCHROIC DISORGAIZED TPE SCHIZOPHREIA, CHROIC DISORGAIZED TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO DISORGAIZED TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO DISORGAIZED TPE SCHIZOPHREIA, I REMISSIO CATATOIC TPE SCHIZOPHREIA, USPECIFIED CATATOIC TPE SCHIZOPHREIA, SUBCHROIC CATATOIC TPE SCHIZOPHREIA, CHROIC CATATOIC TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO CATATOIC TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO CATATOIC TPE SCHIZOPHREIA, I REMISSIO PARAOID TPE SCHIZOPHREIA, USPECIFIED PARAOID TPE SCHIZOPHREIA, SUBCHROIC PARAOID TPE SCHIZOPHREIA, CHROIC PARAOID TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO PARAOID TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO PARAOID TPE SCHIZOPHREIA, I REMISSIO SCHIZOPHREIFORM DISORDER, USPECIFIED SCHIZOPHREIFORM DISORDER, SUBCHROIC SCHIZOPHREIFORM DISORDER, CHROIC SCHIZOPHREIFORM DISORDER, SUBCHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIFORM DISORDER, CHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIFORM DISORDER, I REMISSIO LATET SCHIZOPHREIA, USPECIFIED LATET SCHIZOPHREIA, SUBCHROIC LATET SCHIZOPHREIA, CHROIC LATET SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO LATET SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO LATET SCHIZOPHREIA, I REMISSIO SCHIZOPHREIC DISORDERS, RESIDUAL TPE, USPECIFIED SCHIZOPHREIC DISORDERS, RESIDUAL TPE, SUBCHROIC SCHIZOPHREIC DISORDERS, RESIDUAL TPE, CHROIC SCHIZOPHREIC DISORDERS, RESIDUAL TPE, SUBCHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIC DISORDERS, RESIDUAL TPE, CHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIC DISORDERS, RESIDUAL TPE, I REMISSIO SCHIZOAFFECTIVE DISORDER, USPECIFIED SCHIZOAFFECTIVE DISORDER, SUBCHROIC SCHIZOAFFECTIVE DISORDER, CHROIC
4 29573 SCHIZOAFFECTIVE DISORDER, SUBCHROIC WITH ACUTE EXACERBATIO SCHIZOAFFECTIVE DISORDER, CHROIC WITH ACUTE EXACERBATIO SCHIZOAFFECTIVE DISORDER, I REMISSIO OTHER SPECIFIED TPES OF SCHIZOPHREIA, USPECIFIED OTHER SPECIFIED TPES OF SCHIZOPHREIA, SUBCHROIC OTHER SPECIFIED TPES OF SCHIZOPHREIA, CHROIC OTHER SPECIFIED TPES OF SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO OTHER SPECIFIED TPES OF SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO OTHER SPECIFIED TPES OF SCHIZOPHREIA, I REMISSIO USPECIFIED SCHIZOPHREIA, USPECIFIED USPECIFIED SCHIZOPHREIA, SUBCHROIC USPECIFIED SCHIZOPHREIA, CHROIC USPECIFIED SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO USPECIFIED SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO USPECIFIED SCHIZOPHREIA, I REMISSIO BIPOLAR I DISORDER, SIGLE MAIC EPISODE, USPECIFIED BIPOLAR I DISORDER, SIGLE MAIC EPISODE, MILD BIPOLAR I DISORDER, SIGLE MAIC EPISODE, MODERATE BIPOLAR I DISORDER, SIGLE MAIC EPISODE, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, SIGLE MAIC EPISODE, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, SIGLE MAIC EPISODE, I PARTIAL OR USPECIFIED REMISSIO BIPOLAR I DISORDER, SIGLE MAIC EPISODE, I FULL REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, USPECIFIED BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, MILD BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, MODERATE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, I PARTIAL OR USPECIFIED REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, I FULL REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, USPECIFIED BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, MILD BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, MODERATE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, I FULL REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, USPECIFIED
5 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, MILD BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, MODERATE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, I PARTIAL OR USPECIFIED REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, I FULL REMISSIO 2967 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) USPECIFIED BIPOLAR DISORDER, USPECIFIED ATPICAL MAIC DISORDER OTHER BIPOLAR DISORDER USPECIFIED EPISODIC MOOD DISORDER OTHER SPECIFIED EPISODIC MOOD DISORDER AUTISTIC DISORDER, CURRET OR ACTIVE STATE AUTISTIC DISORDER, RESIDUAL STATE CHILDHOOD DISITEGRATIVE DISORDER, CURRET OR ACTIVE STATE CHILDHOOD DISITEGRATIVE DISORDER, RESIDUAL STATE OTHER SPECIFIED PERVASIVE DEVELOPMETAL DISORDERS, CURRET OR ACTIVE STATE OTHER SPECIFIED PERVASIVE DEVELOPMETAL DISORDERS, RESIDUAL STATE USPECIFIED PERVASIVE DEVELOPMETAL DISORDER, CURRET OR ACTIVE STATE USPECIFIED PERVASIVE DEVELOPMETAL DISORDER, RESIDUAL STATE TOURETTE S DISORDER ICD-10 Code Description F200 PARAOID SCHIZOPHREIA F201 DISORGAIZED SCHIZOPHREIA F202 CATATOIC SCHIZOPHREIA F203 UDIFFERETIATED SCHIZOPHREIA F205 RESIDUAL SCHIZOPHREIA F2081 SCHIZOPHREIFORM DISORDER F2089 OTHER SCHIZOPHREIA F209 SCHIZOPHREIA, USPECIFIED F21 SCHIZOTPAL DISORDER F22 DELUSIOAL DISORDERS F23 BRIEF PSCHOTIC DISORDER F24 SHARED PSCHOTIC DISORDER F250 SCHIZOAFFECTIVE DISORDER, BIPOLAR TPE F251 SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TPE F258 OTHER SCHIZOAFFECTIVE DISORDERS F259 SCHIZOAFFECTIVE DISORDER, USPECIFIED F28 OTHER PSCHOTIC DISORDER OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO F29 USPECIFIED PSCHOSIS OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO F3010 MAIC EPISODE WITHOUT PSCHOTIC SMPTOMS USPECIFIED F3011 MAIC EPISODE WITHOUT PSCHOTIC SMPTOMS MILD F3012 MAIC EPISODE WITHOUT PSCHOTIC SMPTOMS MODERATE F3013 MAIC EPISODE, SEVERE, WITHOUT PSCHOTIC SMPTOMS F302 MAIC EPISODE, SEVERE WITH PSCHOTIC SMPTOMS F303 MAIC EPISODE I PARTIAL REMISSIO
6 F304 F308 F309 F310 F3110 F3111 F3112 F3113 F312 F3130 F3131 F3132 F314 F315 F3160 F3161 F3162 F3163 F3164 F3170 F3171 F3172 F3173 F3174 F3175 F3176 F3177 F3178 F3181 F3189 F319 F340 F341 F3481 F3489 F349 F39 F840 F842 F843 F845 F848 F849 F952 MAIC EPISODE I FULL REMISSIO OTHER MAIC EPISODES MAIC EPISODE, USPECIFIED BIPOLAR DISORDER, CURRET EPISODE HPOMAIC BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES USPECIFIED BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES MILD BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES MODERATE BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES SEVERE BIPOLAR DISORDER, CURRET EPISODE MAIC SEVERE WITH PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, MILD OR MODERATE SEVERIT USPECIFIED BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, MILD BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, MODERATE BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, SEVERE, WITHOUT PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, SEVERE, WITH PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE MIXED USPECIFIED BIPOLAR DISORDER, CURRET EPISODE MIXED MILD BIPOLAR DISORDER, CURRET EPISODE MIXED MODERATE BIPOLAR DISORDER, CURRET EPISODE MIXED SEVERE, WITHOUT PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE MIXED SEVERE, WITH PSCHOTIC FEATURES BIPOLAR DISORDER, CURRETL I REMISSIO MOST RECET EPISODE USPECIFIED BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE HPOMAIC BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE HPOMAIC BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE MAIC BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE MAIC BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE DEPRESSED BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE DEPRESSED BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE MIXED BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE MIXED BIPOLAR II DISORDER OTHER BIPOLAR DISORDER BIPOLAR DISORDER, USPECIFIED CCLOTHMIC DISORDER DSTHMIC DISORDER DISRUPTIVE MOOD DSREGULATIO DISORDER OTHER SPECIFIED PERSISTET MOOD DISORDERS PERSISTET MOOD [AFFECTIVE] DISORDER, USPECIFIED USPECIFIED MOOD [AFFECTIVE] DISORDER AUTISTIC DISORDER RETT'S SDROME OTHER CHILDHOOD DISITEGRATIVE DISORDER ASPERGER'S SDROME OTHER PERVASIVE DEVELOPMETAL DISORDERS PERVASIVE DEVELOPMETAL DISORDER, USPECIFIED TOURETTE S DISORDER
7 ICD-9 Code Description 2970 PARAOID STATE, SIMPLE 2971 DELUSIOAL DISORDER 2972 PARAPHREIA 2973 SHARED PSCHOTIC DISORDER Table B 2978 OTHER SPECIFIED PARAOID STATES 2979 USPECIFIED PARAOID STATE 2989 USPECIFIED PSCHOSIS ITERMITTET EXPLOSIVE DISORDER CODUCT DISORDER, CHILDHOOD OSET CODUCT DISORDER, ADOLESCET OSET CODUCT DISORDER, OSET USPECIFIED OPPOSITIOAL DEFIAT DISORDER ICD-10 Code Description F22 F23 F24 F29 F6381 F911 F912 F913 F919 DELUSIOAL DISORDERS BRIEF PSCHOTIC DISORDER SHARED PSCHOTIC DISORDER USPECIFIED PSCHOSIS OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO ITERMITTET EXPLOSIVE DISORDER CODUCT DISORDER, CHILDHOOD-OSET TPE CODUCT DISORDER, ADOLESCET-OSET TPE OPPOSITIOAL DEFIAT DISORDER CODUCT DISORDER, USPECIFIED Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (or Authorized) Signature Date
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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 503-947-2596
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