Victoza (Liraglutide) Solution for Injection

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 te: Click the hyperlink to navigate directly to that section. Revision tes Initial publication and posting to website July 18, 2012 Copyright 2012 Health Information Designs, LLC 1

2 Victoza (Liraglutide) Solution for Injection Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN VICTOZA 2-PAK 18MG/3ML PEN VICTOZA 3-PAK 18MG/3ML PEN July 18, 2012 Copyright 2012 Health Information Designs, LLC 2

3 Victoza (Liraglutide) Solution for Injection Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 18 years of age? [ ] (Go to #2) [ ] (Deny) 2. Does the client have a diagnosis of type II diabetes in the last 365 days? [ ] (Go to #3) [ ] (Deny) 3. Does the client have a history of an oral antidiabetic agent for at least 14 days in the last 365 days? [ ] (Go to #4) [ ] (Deny) 4. Does the client have a diagnosis of thyroid cancer in the last 730 days? [ ] (Deny) [ ] (Go to #5) 5. Does the client have a diagnosis of type II multiple endocrine neoplasia in the last 730 days? [ ] (Deny) [ ] (Go to #6) 6. Does the client have a history of an HbA1c test in the last 180 days? [ ] (Go to #7) [ ] (Deny) 7. Are the requested units per day less than or equal to ( ) 0.3mL, 1.8mg, or 0.1 pens? [ ] (Approve 365 days) [ ] (Deny) July 18, 2012 Copyright 2012 Health Information Designs, LLC 3

4 Victoza (Liraglutide) Solution for Injection Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client 18 years of age? Does the client have a diagnosis of type II diabetes in the last 365 days? Does the client have a history of an oral antidiabetic agent in the of of the the last last days? Step 4 Does the client have a diagnosis of thyroid cancer in the last 730 days? Step 5 Does the client have a diagnosis of type II multiple endocrine neoplasia in the last 730 days? Step 7 Step 6 Approve Request (365 days) Are the requested units per day 0.3mL,1.8mg, or 0.1 pens? Does the client have a history of an HbA1c test in the last 180 days? July 18, 2012 Copyright 2012 Health Information Designs, LLC 4

5 Victoza (Liraglutide) Solution for Injection Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of type II diabetes) Required diagnosis: 1 ICD-9 Code DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE UNCONTROLLED July 18, 2012 Copyright 2012 Health Information Designs, LLC 5

6 ICD-9 Code Step 2 (diagnosis of type II diabetes) Required diagnosis: DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED Step 3 (history of oral anti-diabetic agent) Number of claims: 1 GCN ACARBOSE 25 MG TABLET ACARBOSE 50 MG TABLET ACARBOSE 100 MG TABLET ACTOPLUS MET 15 MG-500 MG TAB ACTOPLUS MET 15 MG-850 MG TAB ACTOPLUS MET XR 15-1,000 MG TB ACTOPLUS MET XR 30-1,000 MG TB ACTOS 15 MG TABLET ACTOS 30 MG TABLET ACTOS 45 MG TABLET AMARYL 1 MG TABLET AMARYL 2 MG TABLET AMARYL 4 MG TABLET AVANDAMET 2 MG-500 MG TABLET AVANDAMET 2 MG-1,000 MG TAB AVANDAMET 4 MG-500 MG TABLET AVANDAMET 4 MG-1,000 MG TABLET AVANDARYL 4 MG-1 MG TABLET AVANDARYL 4 MG-2 MG TABLET AVANDARYL 4 MG-4 MG TABLET AVANDARYL 8 MG-2 MG TABLET AVANDARYL 8 MG-4 MG TABLET AVANDIA 2 MG TABLET AVANDIA 4 MG TABLET AVANDIA 8 MG TABLET CHLORPROPAMIDE 100 MG TABLET CHLORPROPAMIDE 250 MG TABLET July 18, 2012 Copyright 2012 Health Information Designs, LLC 6

7 Step 3 (history of oral anti-diabetic agent) Number of claims: 1 GCN DIABETA 1.25 MG TABLET DIABETA 2.5 MG TABLET DIABETA 5 MG TABLET DUETACT 30-2 MG TABLET DUETACT 30-4 MG TABLET FORTAMET ER 500 MG TABLET FORTAMET ER 1,000 MG TABLET GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE 10 MG TABLET GLIPIZIDE ER 2.5 MG TABLET GLIPIZIDE ER 5 MG TABLET GLIPIZIDE ER 10 MG TABLET GLIPIZIDE XL 2.5 MG TABLET GLIPIZIDE XL 5 MG TABLET GLIPIZIDE XL 10 MG TABLET GLIPIZIDE-METFORMIN MG GLIPIZIDE-METFORMIN MG GLIPIZIDE-METFORMIN MG GLUCOPHAGE 500 MG TABLET GLUCOPHAGE 850 MG TABLET GLUCOPHAGE 1,000 MG TABLET GLUCOPHAGE XR 500 MG TAB GLUCOPHAGE XR 750 MG TAB GLUCOTROL 5 MG TABLET GLUCOTROL 10 MG TABLET GLUCOTROL XL 2.5 MG TABLET GLUCOTROL XL 5 MG TABLET GLUCOTROL XL 10 MG TABLET GLUCOVANCE MG TABLET GLUCOVANCE MG TABLET GLUMETZA ER 500 MG TABLET GLUMETZA ER 1,000 MG TABLET GLYBURIDE 1.25 MG TABLET July 18, 2012 Copyright 2012 Health Information Designs, LLC 7

8 Step 3 (history of oral anti-diabetic agent) Number of claims: 1 GCN GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRO 1.5 MG TAB GLYBURIDE MICRO 3 MG TABLET GLYBURIDE MICRO 6 MG TABLET GLYBURIDE-METFORMIN MG GLYBURIDE-METFORMIN MG GLYBURID-METFORMIN MG GLYNASE 1.5 MG PRESTAB GLYNASE 3 MG PRESTAB GLYNASE 6 MG PRESTAB GLYSET 25 MG TABLET GLYSET 50 MG TABLET GLYSET 100 MG TABLET JANUMET MG TABLET JANUMET 50-1,000 MG TABLET JANUVIA 25 MG TABLET JANUVIA 50 MG TABLET JANUVIA 100 MG TABLET KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR MG TABLET KOMBIGLYZE XR 5-1,000 MG TAB METAGLIP MG TABLET METFORMIN HCL 500 MG TABLET METFORMIN HCL 850 MG TABLET METFORMIN HCL 1,000 MG TABLET METFORMIN HCL ER 500 MG TABLET METFORMIN HCL ER 500 MG TABLET METFORMIN HCL ER 750 MG TABLET METFORMIN HCL ER 1,000 MG TAB NATEGLINIDE 60 MG TABLET NATEGLINIDE 120 MG TABLET ONGLYZA 2.5 MG TABLET ONGLYZA 5 MG TABLET PRANDIMET 1 MG-500 MG TABLET PRANDIMET 2 MG-500 MG TABLET July 18, 2012 Copyright 2012 Health Information Designs, LLC 8

9 Step 3 (history of oral anti-diabetic agent) Number of claims: 1 GCN PRANDIN 0.5 MG TABLET PRANDIN 1 MG TABLET PRANDIN 2 MG TABLET PRECOSE 25 MG TABLET PRECOSE 50 MG TABLET PRECOSE 100 MG TABLET RIOMET 500 MG/5 ML SOLUTION STARLIX 60 MG TABLET STARLIX 120 MG TABLET TOLAZAMIDE 250 MG TABLET TOLAZAMIDE 500 MG TABLET TOLBUTAMIDE 500 MG TABLET TRADJENTA 5 MG TABLET Step 4 (diagnosis of thyroid cancer) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code 193 MALIGN NEOPL THYROID Step 5 (diagnosis of type II multiple endocrine neoplasia) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code MULTIPLE ENDOCRINE NEOPLASIA [MEN] TYPE IIA Step 6 (history of an HbA1c test) Number of claims: 1 Look back timeframe: 180 days CPT GLYCOSYLATED HEMOGLOBIN TEST July 18, 2012 Copyright 2012 Health Information Designs, LLC 9

10 Victoza (Liraglutide) Solution for Injection Clinical Edit Criteria References 1. Victoza [package insert]. Princeton, NJ: vo rdisk, Inc. Available at Accessed on August 30, Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc., 2011, updated April Available at 96&sec=monindi. July 18, 2012 Copyright 2012 Health Information Designs, LLC 10

11 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 07/18/2012 Initial publication and posting to website July 18, 2012 Copyright 2012 Health Information Designs, LLC 11