Nuplazid (pimavanserin)

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1 Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by the Texas Medicaid Vendor Drug Program to ensure appropriate and safe utilization. Additional MCO recommendations have been incorporated. Clinical Information Included in this Document Nuplazid Tablets 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 References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section Revision Notes Initial Publication July 28, 2017 Copyright Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization NUPLAZID 17 MG TABLETS July 28, 2017 Copyright Health Information Designs, LLC 2

3 Clinical Criteria Logic 1. Does the client have a diagnosis of Parkinson s disease and psychosis with hallucinations and/or delusions in the last 730 days? [ ] Yes (Go to #2) [ ] No (Deny) 2. Does the client have a claim for a drug that increases the QT interval in the last 90 days? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have a diagnosis of hepatic impairment in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #4) 4. Does the client have a claim for a strong CYP3A4 inhibitor in the last 90 days? [ ] Yes (Go to #5) [ ] No (Approve 365 days) 5. Is the request for less than or equal to ( ) 1 tablet per day? [ ] Yes (Approve 365 days) [ ] No (Deny) July 28, 2017 Copyright Health Information Designs, LLC 3

4 Clinical Criteria Logic Diagram Step 1 Step 2 Step 3 Does the client have a diagnosis of Parkinson s disease and psychosis with hallucinations and/or delusions in the last 730 days? Yes Does the client have a claim for a drug that increases QT interval in the last 90 days? No Does the client have a diagnosis of hepatic impairment in the last 730 days? Yes Deny Request No Yes No Step 4 Deny Request Deny Request Does the client have a claim for a strong CYP3A4 inhibitor in the last 90 days? No Approve Request (365 days) Yes Step 5 Is the request for 1 tablet per day? Yes Approve Request (365 days) No Deny Request July 28, 2017 Copyright Health Information Designs, LLC 4

5 Clinical Criteria Supporting Tables Step 1a (diagnosis of Parkinson s disease) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 3320 PARALYSIS AGITANS ICD-10 Code Description G20 PARKINSON S DISEASE ICD-9 Code Step 1b (diagnosis of psychosis with hallucinations and/or delusions) Description Required diagnosis: 1 Look back timeframe: 730 days PSYCHOTIC DISORDER WITH DELUSIONS IN CONDITIONS CLASSIFIED ELSEWHERE PSYCHOTIC DISORDER WITH HALLUCINATIONS IN CONDITIONS CLASSIFIED ELSEWHERE 7801 HALLUCINATIONS ICD-10 Code F060 F062 R443 Description PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION HALLUCINATIONS, UNSPECIFIED ABILIFY 1 MG/ML SOLUTION ABILIFY 10 MG TABLET ABILIFY 15 MG TABLET ABILIFY 2 MG TABLET ABILIFY 20 MG TABLET ABILIFY 30 MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 5

6 ABILIFY 5 MG TABLET ABILIFY DISCMELT 10 MG TABLET ABILIFY DISCMELT 15 MG TABLET ABILIFY MAINTENA ER 300MG SYR ABILIFY MAINTENA ER 300MG VL ABILIFY MAINTENA ER 400MG SYR ABILIFY MAINTENA ER 400MG VL AGRYLIN 0.5 MG CAPSULE ALFUZOSIN HCL ER 10 MG TABLET AMIODARONE HCL 100 MG TABLET AMIODARONE HCL 200 MG TABLET AMIODARONE HCL 400 MG TABLET AMITRIPTYLINE HCL 10 MG TAB AMITRIPTYLINE HCL 100 MG TAB AMITRIPTYLINE HCL 150 MG TAB AMITRIPTYLINE HCL 25 MG TAB AMITRIPTYLINE HCL 50 MG TAB AMITRIPTYLINE HCL 75 MG TAB AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE ANAFRANIL 25 MG CAPSULE ANAFRANIL 50 MG CAPSULE ANAFRANIL 75 MG CAPSULE ANAGRELIDE HCL 0.5 MG CAPSULE ANAGRELIDE HCL 1 MG CAPSULE ANZEMET 100 MG TABLET ANZEMET 50 MG TABLET ARICEPT 10 MG TABLET ARICEPT 23 MG TABLET ARICEPT 5 MG TABLET ARIPIPRAZOLE 10MG TABLET ARIPIPRAZOLE 15MG TABLET ARIPIPRAZOLE 1MG/ML SOLUTION ARIPIPRAZOLE 20MG TABLET ARIPIPRAZOLE 2MG TABLET ARIPIPRAZOLE 30MG TABLET ARIPIPRAZOLE 5MG TABLET ARIPIPRAZOLE ODT 10MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 6

7 ARIPIPRAZOLE ODT 15MG TABLET ARISTADA ER 441MG/1.6ML SYRINGE ARISTADA ER 441MG/1.6ML SYRINGE ARISTADA ER 662MG/2.4ML SYRINGE ARISTADA ER 882MG/3.2ML SYRINGE ATRIPLA TABLET AVELOX 400 MG TABLET AZITHROMYCIN 1 GM PWD PACKET AZITHROMYCIN 100 MG/5 ML SUSP AZITHROMYCIN 200 MG/5 ML SUSP AZITHROMYCIN 250 MG TABLET AZITHROMYCIN 500 MG TABLET AZITHROMYCIN 600 MG TABLET AZITHROMYCIN I.V. 500 MG VIAL BETAPACE 120 MG TABLET BETAPACE 160 MG TABLET BETAPACE 80 MG TABLET BIAXIN 250 MG TABLET BIAXIN 250 MG/5 ML SUSPENSION BIAXIN 500 MG TABLET BRISDELLE 7.5MG CAPSULE CAPRELSA 100 MG TABLET CAPRELSA 300 MG TABLET CELEXA 20MG TABLET CHLORDIAZEPO-AMITRIPTYL CHLORDIAZEPOX-AMITRIPTYL CHLOROQUINE PH 250 MG TABLET CHLOROQUINE PH 500 MG TABLET CHLORPROMAZINE 10 MG TABLET CHLORPROMAZINE 100 MG TABLET CHLORPROMAZINE 100MG/ML CONC CHLORPROMAZINE 200 MG TABLET CHLORPROMAZINE 25 MG TABLET CHLORPROMAZINE 30MG/ML CONC CHLORPROMAZINE 50 MG TABLET CIPRO 10% SUSPENSION CIPRO 250MG TABLET CIPRO 5% SUSPENSION July 28, 2017 Copyright Health Information Designs, LLC 7

8 CIPRO 500MG TABLET CIPROFLOXACIN 200MG/20ML VIAL CIPROFLOXACIN 250MG/5ML SUSP CIPROFLOXACIN 400MG/40ML VIAL CIPROFLOXACIN 500MG/5ML SUSP CIPROFLOXACIN ER 1000MG TAB CIPROFLOXACIN ER 500MG TAB CIPROFLOXACIN HCL 100MG TABLET CIPROFLOXACIN HCL 250MG TAB CIPROFLOXACIN HCL 500MG TAB CIPROFLOXACIN HCL 750MG TAB CIPROFLOXACIN-D5W 200MG/100ML CIPROFLOXACIN-D5W 400MG/200ML CITALOPRAM 10MG TABLET CITALOPRAM 10MG/5ML SOLUTION CITALOPRAM 20MG TABLET CITALOPRAM 20MG/10ML SOLUTION CITALOPRAM 40MG TABLET 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 CLOMIPRAMINE 25 MG CAPSULE CLOMIPRAMINE 50 MG CAPSULE CLOMIPRAMINE 75 MG CAPSULE CLOZAPINE 100 MG TABLET CLOZAPINE 12.5MG TABLET CLOZAPINE 200 MG TABLET CLOZAPINE 25 MG TABLET CLOZAPINE 50 MG TABLET CLOZAPINE ODT 100MG TABLET CLOZAPINE ODT 12.5MG TABLET CLOZAPINE ODT 25MG TABLET CLOZARIL 100 MG TABLET CLOZARIL 25 MG TABLET CORDARONE 200 MG TABLET CYCLOBENZAPRINE 10 MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 8

9 CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 7.5 MG TABLET DESIPRAMINE 10 MG TABLET DESIPRAMINE 100 MG TABLET DESIPRAMINE 150 MG TABLET DESIPRAMINE 25 MG TABLET DESIPRAMINE 50 MG TABLET DESIPRAMINE 75 MG TABLET DETROL 1 MG TABLET DETROL 2 MG TABLET DETROL LA 2 MG CAPSULE DETROL LA 4 MG CAPSULE DIFLUCAN 10 MG/ML SUSPENSION DIFLUCAN 100 MG TABLET DIFLUCAN 150 MG TABLET DIFLUCAN 200 MG TABLET DIFLUCAN 40 MG/ML SUSPENSION DIFLUCAN 50 MG TABLET DOFETILIDE 125 MCG CAPSULE DOFETILIDE 250MCG CAPSULE DOFETILIDE 500MCG CAPSULE DOLOPHINE HCL 10 MG TABLET DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL 23 MG TABLET DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL ODT 10 MG TABLET DONEPEZIL HCL ODT 5 MG TABLET DOXEPIN 10 MG CAPSULE DOXEPIN 10 MG/ML ORAL CONC DOXEPIN 100 MG CAPSULE DOXEPIN 150 MG CAPSULE DOXEPIN 25 MG CAPSULE DOXEPIN 50 MG CAPSULE DOXEPIN 75 MG CAPSULE DUEXIS MG TABLET E.E.S. 200 MG/5 ML GRANULES E.E.S. 400 FILMTAB EFFEXOR XR 150MG CAPSULE July 28, 2017 Copyright Health Information Designs, LLC 9

10 EFFEXOR XR 37.5MG CAPSULE EFFEXOR XR 75MG CAPSULE ENVARSUS XR 0.75 MG TABLET ENVARSUS XR 1 MG TABLET ENVARSUS XR 4 MG TABLET ERYPED 200 MG/5 ML SUSPENSION ERYPED 400 MG/5 ML SUSPENSION ERY-TAB EC 250 MG TABLET ERY-TAB EC 333 MG TABLET ERY-TAB EC 500 MG TABLET ERYTHROCIN 250 MG FILMTAB ERYTHROCIN 500 MG ADDVNT VL ERYTHROCIN 500 MG VIAL ERYTHROMYCIN 250 MG FILMTAB ERYTHROMYCIN 500 MG FILMTAB ERYTHROMYCIN EC 250 MG CAP ERYTHROMYCIN ES 400 MG TAB ESCITALOPRAM 10MG TABLET ESCITALOPRAM 20MG TABLET ESCITALOPRAM 5MG TABLET ESCITALOPRAM 5MG/5ML SOLUTION EVOTAZ MG TABLET FAMOTIDINE 10 MG TABLET FAMOTIDINE 20 MG TABLET FAMOTIDINE 40 MG TABLET FAMOTIDINE 40 MG/5 ML SUSP FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET FANAPT TITRATION PACK FAZACLO 100 MG ODT FAZACLO 12.5 MG ODT FAZACLO 150 MG ODT FAZACLO 200 MG ODT July 28, 2017 Copyright Health Information Designs, LLC 10

11 FAZACLO 25 MG ODT FELBAMATE 400 MG TABLET FELBAMATE 600 MG TABLET FELBAMATE 600 MG/5 ML SUSP FELBATOL 400 MG TABLET FELBATOL 600 MG TABLET FELBATOL 600 MG/5 ML SUSP FEXMID 7.5 MG TABLET FLAGYL 250 MG TABLET FLAGYL 375 MG CAPSULE FLAGYL 500 MG TABLET FLAGYL ER 750 MG TABLET FLECAINIDE ACETATE 100 MG TAB FLECAINIDE ACETATE 150 MG TAB FLECAINIDE ACETATE 50 MG TAB FLUCONAZOLE 10 MG/ML SUSP FLUCONAZOLE 100 MG TABLET FLUCONAZOLE 150 MG TABLET FLUCONAZOLE 200 MG TABLET FLUCONAZOLE 40 MG/ML SUSP FLUCONAZOLE 50 MG TABLET FLUCONAZOLE-DEXT 200 MG/100 ML FLUCONAZOLE-NACL 200 MG/100 ML FLUCONAZOLE-NACL 400 MG/200 ML FLUCONAZOLE-NS 200 MG/100 ML FLUOXETINE 10MG CAPSULE FLUOXETINE 10MG TABLET FLUOXETINE 20MG CAPSULE FLUOXETINE 20MG TABLET FLUOXETINE 20MG/5ML SOLUTION FLUOXETINE 40MG CAPSULE FLUOXETINE 60MG TABLET FLUOXETINE DR 90MG CAPSULE GALANTAMINE 4 MG/ML ORAL SOLN GALANTAMINE ER 16 MG CAPSULE GALANTAMINE ER 24 MG CAPSULE GALANTAMINE ER 8 MG CAPSULE GALANTAMINE HBR 12 MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 11

12 GALANTAMINE HBR 4 MG TABLET GALANTAMINE HBR 8 MG TABLET GEODON 20 MG CAPSULE GEODON 20 MG VIAL GEODON 40 MG CAPSULE GEODON 60 MG CAPSULE GEODON 80 MG CAPSULE GILENYA 0.5 MG CAPSULE GRANISETRON HCL 1 MG TABLET GRANISETRON HCL 1 MG/ML VIAL GRANISETRON HCL 4 MG/4 ML VIAL HYDROXYCHLOROQUINE 200 MG TAB HYDROXYZINE 10 MG/5 ML SYRUP HYDROXYZINE 25 MG/ML VIAL HYDROXYZINE HCL 10 MG TABLET HYDROXYZINE HCL 25 MG TABLET HYDROXYZINE HCL 50 MG TABLET HYDROXYZINE PAM 100 MG CAP HYDROXYZINE PAM 25 MG CAP HYDROXYZINE PAM 50 MG CAP INVEGA ER 1.5 MG TABLET INVEGA ER 3 MG TABLET INVEGA ER 6 MG TABLET INVEGA ER 9 MG TABLET INVEGA SUSTENNA 117 MG PREF SYR INVEGA SUSTENNA 156 MG PREF SYR INVEGA SUSTENNA 234 MG PREF SYR INVEGA SUSTENNA 39 MG PREF SYR INVEGA SUSTENNA 78 MG PREF SYR INVEGA TRINZA 273MG/0.875ML INVEGA TRINZA 410MG/1.315ML INVEGA TRINZA 546MG/1.75ML INVEGA TRINZA 819MG/2.625ML INVIRASE 200MG CAPSULE INVIRASE 500MG TABLET ITRACONAZOLE 100 MG CAPSULE KALETRA MG TABLET KALETRA MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 12

13 KALETRA /5 ML ORAL SOLU KETEK 300 MG TABLET KETEK 400 MG TABLET KETOCONAZOLE 200 MG TABLET KORLYM 300 MG TABLET LANSOPRAZOL-AMOXICIL-CLARITHRO LEUPROLIDE 2WK 1 MG/0.2 ML KIT LEUPROLIDE 2WK 14 MG/2.8 ML KIT LEVAQUIN 250 MG TABLET LEVAQUIN 500 MG TABLET LEVAQUIN 750 MG TABLET LEVOFLOXACIN 25 MG/ML SOLUTION LEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN 250 MG/50 ML-D5W LEVOFLOXACIN 500 MG TABLET LEVOFLOXACIN 500 MG/100 ML-D5W LEVOFLOXACIN 500 MG/20 ML VIAL LEVOFLOXACIN 750 MG TABLET LEVOFLOXACIN 750 MG/150 ML-D5W LEXAPRO 10MG TABLET LEXAPRO 20MG TABLET LEXAPRO 5 MG TABLET LEXAPRO 5MG/5ML SOLUTION LUPRON DEPOT MG 3MO KIT LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT-4MO KIT LUPRON DEPOT-PED KIT LUPRON DEPOT-PED MG 3MO LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED 7.5 MG KIT MEFLOQUINE HCL 250 MG TABLET METHADONE 10 MG/5 ML SOLUTION METHADONE 10 MG/ML ORAL CONC METHADONE 40 MG TABLET DISPR July 28, 2017 Copyright Health Information Designs, LLC 13

14 METHADONE 5 MG/5 ML SOLUTION METHADONE HCL 10 MG TABLET METHADONE HCL 5 MG TABLET METHADOSE 10 MG/ML ORAL CONC METHADOSE 40 MG TABLET DISPR METRONIDAZOLE 250 MG TABLET METRONIDAZOLE 375 MG CAPSULE METRONIDAZOLE 500 MG TABLET METRONIDAZOLE 500 MG/100 ML MOXIFLOXACIN HCL 400 MG TABLET MULTAQ 400 MG TABLET NAMZARIC MG CAPSULE NAMZARIC MG CAPSULE NAMZARIC MG CAPSULE NAMZARIC 7-10 MG CAPSULE NAMZARIC TITRATION PACK NEXAVAR 200 MG TABLET NORPRAMIN 10 MG TABLET NORPRAMIN 25 MG TABLET NORVIR 100 MG SOFTGEL CAP NORVIR 100 MG TABLET NORVIR 80 MG/ML SOLUTION OFLOXACIN 400 MG TABLET OLANZAPINE 10 MG TABLET OLANZAPINE 10 MG VIAL OLANZAPINE 15 MG TABLET OLANZAPINE 2.5 MG TABLET OLANZAPINE 20MG TABLET OLANZAPINE 5 MG TABLET OLANZAPINE 7.5 MG TABLET OLANZAPINE ODT 10 MG TABLET OLANZAPINE ODT 15 MG TABLET OLANZAPINE ODT 20MG TABLET OLANZAPINE ODT 5MG TABLET OLANZAPINE/FLUOXETINE MG OLANZAPINE/FLUOXETINE MG OLANZAPINE/FLUOXETINE 3-25 MG OLANZAPINE/FLUOXETINE 6-25 MG July 28, 2017 Copyright Health Information Designs, LLC 14

15 OLANZAPINE/FLUOXETINE 6-50 MG OLEPTRO ER 150MG TABLET OLEPTRO ER 300MG TABLET OMECLAMOX-PAK COMBO PACK ONDANSETRON 4 MG/5 ML SOLUTION ONDANSETRON 40 MG/20 ML VIAL ONDANSETRON HCL 4 MG TABLET ONDANSETRON HCL 4 MG/2 ML VIAL ONDANSETRON HCL 8 MG TABLET ONDANSETRON ODT 4 MG TABLET ONDANSETRON ODT 8 MG TABLET ORAP 1 MG TABLET ORAP 2 MG TABLET PACERONE 100 MG TABLET PACERONE 200 MG TABLET PACERONE 400 MG TABLET PALIPERIDONE ER 1.5 MG TABLET PALIPERIDONE ER 3 MG TABLET PALIPERIDONE ER 6 MG TABLET PALIPERIDONE ER 9 MG TABLET PAROXETINE 10MG TABLET PAROXETINE 10MG/5ML SUSPENSION PAROXETINE 20MG TABLET PAROXETINE 30MG TABLET PAROXETINE 40MG TABLET PAROXETINE CR 12.5MG TABLET PAROXETINE CR 25MG TABLET PAROXETINE CR 37.5MG TABLET PAXIL 20MG TABLET PAXIL 30MG TABLET PCE 333 MG TABLET PCE 500 MG TABLET PEPCID 40 MG/5 ML ORAL SUSP PERPHEN-AMITRIP 2 MG-10 MG TAB PERPHEN-AMITRIP 2 MG-25 MG TAB PERPHEN-AMITRIP 4 MG-10 MG TAB PERPHEN-AMITRIP 4 MG-25 MG TAB PERPHEN-AMITRIP 4 MG-50 MG TAB July 28, 2017 Copyright Health Information Designs, LLC 15

16 PERPHENAZINE 16 MG TABLET PERPHENAZINE 2 MG TABLET PERPHENAZINE 4 MG TABLET PERPHENAZINE 8 MG TABLET PEXEVA 10MG TABLET PEXEVA 20MG TABLET PEXEVA 30MG TABLET PEXEVA 40MG TABLET PHENADOZ 25 MG SUPP PHENERGAN 25 MG/ML VIAL PIMOZIDE 1 MG TABLET PIMOZIDE 2 MG TABLET PLAQUENIL 200 MG TAB PREVPAC PATIENT PACK PROCHLORPERAZINE 10 MG TAB PROCHLORPERAZINE 25 MG SUPP PROCHLORPERAZINE 5 MG TABLET PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE PROMETHAZINE 12.5 MG TABLET PROMETHAZINE 12.5MG SUPP PROMETHAZINE 25 MG SUPP PROMETHAZINE 25 MG TABLET PROMETHAZINE 25 MG/ML AMPUL PROMETHAZINE 25 MG/ML VIAL PROMETHAZINE 50 MG SUPP PROMETHAZINE 50 MG TABLET PROMETHAZINE 50 MG/ML AMPUL PROMETHAZINE 50 MG/ML VIAL PROMETHAZINE 6.25 MG/5 ML SYR PROMETHAZINE VC SYRUP PROMETHAZINE VC-CODEINE SYRUP PROMETHAZINE-CODEINE SYRUP PROMETHAZINE-DM SYRUP PROMETHEGAN 12.5 MG SUPP PROMETHEGAN 25 MG SUPP PROMETHEGAN 50 MG SUPP July 28, 2017 Copyright Health Information Designs, LLC 16

17 PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL 225 MG TAB PROPAFENONE HCL 300 MG TAB PROPAFENONE HCL ER 225 MG CAP PROPAFENONE HCL ER 325 MG CAP PROPAFENONE HCL ER 425 MG CAP PROTRIPTYLINE HCL 10 MG TABLET PROTRIPTYLINE HCL 5 MG TABLET PROZAC 10MG PULVULE PROZAC 20MG PULVULE PROZAC 20MG/5ML SOLUTION PYLERA CAPSULE QUETIAPINE 100 MG TABLET QUETIAPINE 200 MG TABLET QUETIAPINE 25 MG TABLET QUETIAPINE 300 MG TABLET QUETIAPINE 400 MG TABLET QUETIAPINE 50 MG TABLET QUINIDINE GLUC ER 324 MG TABLET QUINIDINE SULFATE 200 MG TABLET QUINIDINE SULFATE 300 MG TABLET QUININE SULFATE 324 MG CAPSULE RANEXA ER 1,000 MG TABLET RANEXA ER 500 MG TABLET RAZADYNE 12 MG TABLET RAZADYNE 4 MG TABLET RAZADYNE 8 MG TABLET RAZADYNE ER 16 MG CAPSULE RAZADYNE ER 24 MG CAPSULE RAZADYNE ER 8 MG CAPSULE REYATAZ 150 MG CAPSULE REYATAZ 200 MG CAPSULE REYATAZ 300 MG CAPSULE REYATAZ 50 MG POWDER PACKET RISPERDAL 0.25 MG TABLET RISPERDAL 0.5 MG TABLET RISPERDAL 1 MG TABLET RISPERDAL 1 MG/ML SOLUTION July 28, 2017 Copyright Health Information Designs, LLC 17

18 RISPERDAL 2 MG TABLET RISPERDAL 3 MG TABLET RISPERDAL 4 MG TABLET RISPERDAL CONSTA 12.5 MG SYR RISPERDAL CONSTA 25 MG SYR RISPERDAL CONSTA 37.5 MG SYR RISPERDAL CONSTA 50 MG SYR RISPERDAL M-TAB 0.5 MG ODT RISPERDAL M-TAB 1 MG ODT RISPERDAL M-TAB 2 MG ODT RISPERDAL M-TAB 3 MG ODT RISPERDAL M-TAB 4 MG ODT RISPERIDONE 0.25 MG ODT RISPERIDONE 0.25 MG TABLET RISPERIDONE 0.5 MG ODT RISPERIDONE 0.5 MG TABLET RISPERIDONE 1 MG ODT RISPERIDONE 1 MG TABLET RISPERIDONE 1 MG/ML SOLUTION RISPERIDONE 2 MG ODT RISPERIDONE 2 MG TABLET RISPERIDONE 3 MG ODT RISPERIDONE 3 MG TABLET RISPERIDONE 4 MG ODT RISPERIDONE 4 MG TABLET SANCUSO 3.1 MG/24 HR PATCH SAPHRIS 10 MG TAB SUBLINGUAL SAPHRIS 2.5 MG TABLET SUBLINGUAL SAPHRIS 5 MG TABLET SUBLINGUAL SEROQUEL 100 MG TABLET SEROQUEL 200 MG TABLET SEROQUEL 25 MG TABLET SEROQUEL 300 MG TABLET SEROQUEL 400 MG TABLET SEROQUEL 50 MG TABLET SEROQUEL XR 150 MG TABLET SEROQUEL XR 200 MG TABLET SEROQUEL XR 300 MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 18

19 SEROQUEL XR 400 MG TABLET SEROQUEL XR 50 MG TABLET SOLTAMOX 10 MG/5 ML SOLN SORINE 120 MG TABLET SORINE 160 MG TABLET SORINE 240 MG TABLET SORINE 80 MG TABLET SOTALOL 120 MG TABLET SOTALOL 160 MG TABLET SOTALOL 240 MG TABLET SOTALOL 80 MG TABLET SPORANOX 10 MG/ML SOLUTION SPORANOX 100 MG CAPSULE SPRYCEL 100 MG TABLET SPRYCEL 140MG TABLET SPRYCEL 20 MG TABLET SPRYCEL 50 MG TABLET SPRYCEL 70 MG TABLET SPRYCEL 80 MG TABLET SUSTIVA 200MG CAPSULE SUSTIVA 50MG CAPSULE SUSTIVA 600MG TABLET SUTENT 12.5 MG CAPSULE SUTENT 25 MG CAPSULE SUTENT 37.5 MG CAPSULE SUTENT 50 MG CAPSULE SYMBYAX MG CAPSULE SYMBYAX MG CAPSULE SYMBYAX 3-25 MG CAPSULE SYMBYAX 6-25 MG CAPSULE SYMBYAX 6-50 MG CAPSULE TACROLIMUS 0.5 MG CAPSULE TACROLIMUS 1 MG CAPSULE TACROLIMUS 5 MG CAPSULE TAMOXIFEN 10 MG TABLET TAMOXIFEN 20 MG TABLET TASIGNA 150 MG CAPSULE TASIGNA 200 MG CAPSULE July 28, 2017 Copyright Health Information Designs, LLC 19

20 TECHNIVIE DOSE PACK THIORIDAZINE 10 MG TABLET THIORIDAZINE 100 MG TABLET THIORIDAZINE 25 MG TABLET THIORIDAZINE 50 MG TABLET TIKOSYN 125 MCG CAPSULE TIKOSYN 250 MCG CAPSULE TIKOSYN 500 MCG CAPSULE TIZANIDINE HCL 2 MG CAPSULE TIZANIDINE HCL 2 MG TABLET TIZANIDINE HCL 4 MG CAPSULE TIZANIDINE HCL 4 MG TABLET TIZANIDINE HCL 6 MG CAPSULE TOLTERODINE TART ER 2 MG CAP TOLTERODINE TART ER 4 MG CAP TOLTERODINE TARTRATE 1 MG TAB TOLTERODINE TARTRATE 2 MG TAB TRAZODONE 100MG TABLET TRAZODONE 100MG TABLET TRAZODONE 150MG TABLET TRAZODONE 150MG TABLET TRAZODONE 300MG TABLET TRAZODONE 50MG TABLET TRAZODONE 50MG TABLET TRIMIPRAMINE MALEATE 100 MG CAP TRIMIPRAMINE MALEATE 25 MG CAP TRIMIPRAMINE MALEATE 50 MG CAP TYKERB 250 MG TABLET VENLAFAXINE 100MG TABLET VENLAFAXINE 25MG TABLET VENLAFAXINE 37.5MG TABLET VENLAFAXINE 50MG TABLET VENLAFAXINE 75MG TABLET VENLAFAXINE ER 150MG CAPSULE VENLAFAXINE ER 150MG TABLET VENLAFAXINE ER 225MG TABLET VENLAFAXINE ER 37.5MG CAPSULE VENLAFAXINE ER 37.5MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 20

21 VENLAFAXINE ER 75MG CAPSULE VENLAFAXINE ER 75MG TABLET VESICARE 10 MG TABLET VESICARE 5 MG TABLET VFEND 200 MG TABLET VFEND 40 MG/ML SUSPENSION VFEND 50 MG TABLET VFEND IV 200 MG VIAL VIEKIRA PAK VIEKIRA XR TABLET VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VISTARIL 25 MG CAPSULE VISTARIL 50 MG CAPSULE VORICONAZOLE 200 MG TABLET VORICONAZOLE 200 MG VIAL VORICONAZOLE 40 MG/ML SUSP VORICONAZOLE 50 MG TABLET VOTRIENT 200 MG TABLET XALKORI 200 MG CAPSULE XALKORI 250 MG CAPSULE ZANAFLEX 2 MG CAPSULE ZANAFLEX 4 MG CAPSULE ZANAFLEX 4MG TABLET ZANAFLEX 6 MG CAPSULE ZELBORAF 240 MG TABLET ZIPRASIDONE 20 MG CAPSULE ZIPRASIDONE 40 MG CAPSULE ZIPRASIDONE 60 MG CAPSULE ZIPRASIDONE 80 MG CAPSULE ZITHROMAX 1 GM POWDER PACKET ZITHROMAX 100 MG/5 ML SUSP ZITHROMAX 200 MG/5 ML SUSP ZITHROMAX 250 MG TABLET ZITHROMAX 500 MG TABLET ZITHROMAX 600 MG TABLET ZITHROMAX I.V. 500 MG VIAL ZMAX 2 G/60 ML ORAL SUSPENSION July 28, 2017 Copyright Health Information Designs, LLC 21

22 ZOFRAN 2 MG/ML VIAL ZOFRAN 4 MG TABLET ZOFRAN 4 MG/5 ML ORAL SOLN ZOFRAN 8 MG TABLET ZOFRAN ODT 4 MG TABLET ZOFRAN ODT 8 MG TABLET ZYPREXA 10 MG TABLET ZYPREXA 10 MG VIAL ZYPREXA 15 MG TABLET ZYPREXA 2.5 MG TABLET ZYPREXA 20 MG TABLET ZYPREXA 5 MG TABLET ZYPREXA 7.5 MG TABLET ZYPREXA RELPREVV 210 MG VIAL ZYPREXA RELPREVV 300 MG VIAL ZYPREXA RELPREVV 405 MG VIAL ZYPREXA ZYDIS 10 MG TABLET ZYPREXA ZYDIS 15 MG TABLET ZYPREXA ZYDIS 20 MG TABLET ZYPREXA ZYDIS 5 MG TABLET ICD-9 Code Step 3 (diagnosis of hepatic impairment) Description Required diagnosis: 1 Look back timeframe: 730 days 0700 VIRAL HEPATITIS A WITH HEPATIC COMA 0701 VIRAL HEPATITIS A WITHOUT MENTION OF HEPATIC COMA VIRAL HEPATITIS B WITH HEPATIC COMA, ACUTE OR UNSPECIFIED, WITHOUT MENTION OF HEPATITIS DELTA VIRAL HEPATITIS B WITH HEPATIC COMA, ACUTE OR UNSPECIFIED, WITH HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITHOUT HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA, ACUTE OR UNSPECIFIED, WITHOUT MENTION OF HEPATITIS DELTA July 28, 2017 Copyright Health Information Designs, LLC 22

23 Step 3 (diagnosis of hepatic impairment) Required diagnosis: 1 Look back timeframe: 730 days VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA, ACUTE OR UNSPECIFIED, WITH HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA WITHOUT MENTION OF HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA WITH HEPATITIS DELTA ACUTE HEPATITIS C WITH HEPATIC COMA HEPATITIS DELTA WITHOUT MENTION OF ACTIVE HEPATITIS B DISEASE WITH HEPATIC COMA HEPATITIS E WITH HEPATIC COMA CHRONIC HEPATITIS C WITH HEPATIC COMA OTHER SPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA ACUTE HEPATITIS C WITHOUT MENTION OF HEPATIC COMA HEPATITIS DELTA WITHOUT MENTION OF ACTIVE HEPATITIS B DISEASE OR HEPATIC COMA HEPATITIS E WITHOUT MENTION OF HEPATIC COMA CHRONIC HEPATITIS C WITHOUT MENTION OF HEPATIC COMA OTHER SPECIFIED VIRAL HEPATITIS WITHOUT MENTION OF HEPATIC COMA 0706 UNSPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITH HEPATIC COMA 0709 UNSPECIFIED VIRAL HEPATITIS WITHOUT MENTION OF HEPATIC COMA 570 ACUTE AND SUBACUTE NECROSIS OF LIVER 5710 ALCOHOLIC FATTY LIVER 5711 ACUTE ALCOHOLIC HEPATITIS 5712 ALCOHOLIC CIRRHOSIS OF LIVER 5713 ALCOHOLIC LIVER DAMAGE, UNSPECIFIED CHRONIC HEPATITIS, UNSPECIFIED CHRONIC PERSISTENT HEPATITIS OTHER CHRONIC HEPATITIS 5715 CIRRHOSIS OF LIVER WITHOUT MENTION OF ALCOHOL 5716 BILIARY CIRRHOSIS 5718 OTHER CHRONIC NONALCOHOLIC LIVER DISEASE 5719 UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT MENTION OF ALCOHOL 5722 HEPATIC ENCEPHALOPATHY 5728 OTHER SEQUELAE OF CHRONIC LIVER DISEASE 5730 CHRONIC PASSIVE CONGESTION OF LIVER 5731 HEPATITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE July 28, 2017 Copyright Health Information Designs, LLC 23

24 Step 3 (diagnosis of hepatic impairment) Required diagnosis: 1 Look back timeframe: 730 days 5732 HEPATITIS IN OTHER INFECTIOUS DISEASES CLASSIFIED ELSEWHERE 5733 HEPATITIS, UNSPECIFIED 5734 HEPATIC INFARCTION 5738 OTHER SPECIFIED DISORDERS OF LIVER 5739 UNSPECIFIED DISORDER OF LIVER ICD-10 Code B160 B161 B162 B169 B170 B1710 B1711 B172 B178 B179 B180 B181 B182 B188 B189 B190 B1910 B1911 B1920 B1921 B199 K700 K7010 K7011 K702 K7030 K7031 K7040 K7041 K709 Description ACUTE HEPATITIS B WITH DELTA-AGENT WITH HEPATIC COMA ACUTE HEPATITIS B WITH DELTA-AGENT WITHOUT HEPATIC COMA ACUTE HEPATITIS B WITHOUT DELTA-AGENT WITH HEPATIC COMA ACUTE HEPATITIS B WITHOUT DELTA-AGENT AND WITHOUT HEPATIC COMA ACUTE DELTA-(SUPER) INFECTION OF HEPATITIS B CARRIER ACUTE HEPATITIS C WITHOUT HEPATIC COMA ACUTE HEPATITIS C WITH HEPATIC COMA ACUTE HEPATITIS E OTHER SPECIFIED ACUTE VIRAL HEPATITIS ACUTE VIRAL HEPATITIS, UNSPECIFIED CHRONIC VIRAL HEPATITIS B WITH DELTA-AGENT CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENT CHRONIC VIRAL HEPATITIS C OTHER CHRONIC VIRAL HEPATITIS CHRONIC VIRAL HEPATITIS, UNSPECIFIED UNSPECIFIFED VIRAL HEPATITIS WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS B WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS B WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS C WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA ALCOHOLIC FATTY LIVER ALCOHOLIC HEPATITIS WITHOUT ASCITES ALCOHOLIC HEPATITIS WITH ASCITES ALCOHOLIC FIBROSIS AND SCLEROSIS OF LIVER ALCOHOLIC CIRRHOSIS OF LIVER WITHOUT ASCITES ALCOHOLIC CIRRHOSIS OF LIVER WITH ASCITES ALCOHOLIC HEPATIC FAILURE WITHOUT COMA ALCOHOLIC HEPATIC FAILURE WITH COMA ALCOHOLIC LIVER DISEASE, UNSPECIFIED July 28, 2017 Copyright Health Information Designs, LLC 24

25 K7200 K7201 K7210 K7211 K7290 K7291 K730 K731 K732 K738 K739 K740 K741 K742 K743 K744 K745 K7460 K7469 K761 K763 K7689 K769 K77 Step 3 (diagnosis of hepatic impairment) Required diagnosis: 1 Look back timeframe: 730 days ACUTE AND SUBACUTE HEPATIC FAILURE WITHOUT COMA ACUTE AND SUBACUTE HEPATIC FAILURE WITH COMA CHRONIC HEPATIC FAILURE WITHOUT COMA CHRONIC HEPATIC FAILURE WITH COMA HEPATIC FAILURE, UNSPECIFIED WITHOUT COMA HEPATIC FAILURE, UNSPECIFIED WITH COMA CHRONIC PERSISTENT HEPATITIS, NOT ELSEWHERE CLASSIFIED CHRONIC LOBULAR HEPATITIS, NOT ELSEWHERE CLASSIFIED CHRONIC ACTIVE HEPATITIS, NOT ELSEWHERE CLASSIFIED OTHER CHRONIC HEPATITIS, NOT ELSEWHERE CLASSIFIED CHRONIC HEPATITIS, UNSPECIFIED HEPATIC FIBROSIS HEPATIC SCLEROSIS HEPATIC FIBROSIS WITH HEPATIC SCLEROSIS PRIMARY BILIARY CIRRHOSIS SECONDARY BILIARY CIRRHOSIS BILIARY CIRRHOSIS, UNSPECIFIED UNSPECIFIED CIRRHOSIS OF LIVER OTHER CIRRHOSIS OF LIVER CHRONIC PASSIVE CONGESTION OF LIVER INFARCTION OF LIVER OTHER SPECIFIED DISEASES OF LIVER LIVER DISEASE, UNSPECIFIED LIVER DISORDERS IN DISEASES CLASSIFIED ELSEWHERE Step 4 (claim for a strong CYP3A4 inhibitor) BIAXIN 250 MG TABLET BIAXIN 250 MG/5 ML SUSPENSION BIAXIN 500 MG TABLET CARDIZEM 120 MG TABLET CARDIZEM 30 MG TABLET CARDIZEM 60 MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 25

26 Step 4 (claim for a strong CYP3A4 inhibitor) CARDIZEM CD 120 MG CAPSULE CARDIZEM CD 180 MG CAPSULE CARDIZEM CD 240 MG CAPSULE CARDIZEM CD 300 MG CAPSULE CARDIZEM CD 360 MG CAPSULE CARDIZEM LA 120 MG TABLET CARDIZEM LA 180 MG TABLET CARDIZEM LA 360 MG TABLET CARDIZEM LA 420 MG TABLET CARTIA XT 120MG CAPSULE CARTIA XT 180MG CAPSULE CARTIA XT 240MG CAPSULE CARTIA XT 300MG 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 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE DILTIAZEM 120 MG TABLET DILTIAZEM 12HR ER 120 MG CAP DILTIAZEM 12HR ER 60 MG CAP DILTIAZEM 12HR ER 90 MG CAP DILTIAZEM 24HR ER 120 MG CAP DILTIAZEM 24HR ER 180 MG CAP DILTIAZEM 24HR ER 240 MG CAP DILTIAZEM 24HR ER 300 MG CAP DILTIAZEM 24HR ER 360 MG CAP DILTIAZEM 30 MG TABLET DILTIAZEM 60 MG TABLET DILTIAZEM 90 MG TABLET DILTIAZEM ER 120 MG CAPSULE DILTIAZEM ER 120 MG CAPSULE DILTIAZEM ER 180 MG CAPSULE DILTIAZEM ER 180 MG CAPSULE DILTIAZEM ER 240 MG CAPSULE DILTIAZEM HCL ER 240 MG CAP July 28, 2017 Copyright Health Information Designs, LLC 26

27 Step 4 (claim for a strong CYP3A4 inhibitor) DILTIAZEM HCL ER 300 MG CAP DILTIAZEM HCL ER 360 MG CAP DILTIAZEM HCL ER 420 MG CAP EVOTAZ MG TABLET GENVOYA TABLET INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET ITRACONAZOLE 100 MG CAPSULE KALETRA MG TABLET KALETRA MG TABLET KALETRA /5 ML ORAL SOLU KETEK 300 MG TABLET KETEK 400 MG TABLET KETOCONAZOLE 200 MG TABLET LANSOPRAZOL-AMOXICIL-CLARITHRO MATZIM LA 180MG TABLET MATZIM LA 240MG TABLET MATZIM LA 300MG TABLET MATZIM LA 360MG TABLET MATZIM LA 420MG TABLET NEFAZODONE 100MG TABLET NEFAZODONE 150MG TABLET NEFAZODONE 200MG TABLET NEFAZODONE 250MG TABLET NEFAZODONE 50MG TABLET NORVIR 100 MG SOFTGEL CAP NORVIR 100 MG TABLET NORVIR 80 MG/ML SOLUTION NOXAFIL 40 MG/ML SUSPENSION NOXAFIL DR 100 MG TABLET OMECLAMOX-PAK COMBO PACK PREVPAC PATIENT PACK PREZCOBIX MG TABLET SPORANOX 10 MG/ML SOLUTION SPORANOX 100 MG CAPSULE STRIBILD TABLET TAZTIA XT 120MG CAPSULE TAZTIA XT 180MG CAPSULE July 28, 2017 Copyright Health Information Designs, LLC 27

28 Step 4 (claim for a strong CYP3A4 inhibitor) TAZTIA XT 240MG CAPSULE TAZTIA XT 300MG CAPSULE TAZTIA XT 360MG CAPSULE TECHNIVIE DOSE PACK TIAZAC ER 120MG CAPSULE TIAZAC ER 180MG CAPSULE TIAZAC ER 240MG CAPSULE TIAZAC ER 300MG CAPSULE TIAZAC ER 360MG CAPSULE TIAZAC ER 420MG CAPSULE TYBOST 150MG TABLET VFEND 200 MG TABLET VFEND 40 MG/ML SUSPENSION VFEND 50 MG TABLET VFEND IV 200 MG VIAL VICTRELIS 200 MG CAPSULE VIEKIRA PAK VIEKIRA XR TABLET VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VORICONAZOLE 200 MG TABLET VORICONAZOLE 200 MG VIAL VORICONAZOLE 40 MG/ML SUSP VORICONAZOLE 50 MG TABLET ZYDELIG 100MG TABLET ZYDELIG 150MG TABLET July 28, 2017 Copyright Health Information Designs, LLC 28

29 Clinical Criteria References ICD-9-CM Diagnosis Codes Available at Accessed on July 28, ICD-10-CM Diagnosis Codes Available at Accessed on July 28, Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on July 28, Micromedex [online database] Available at Accessed on July 28, Nuplazid Prescribing Information. San Diego, CA. Acadia Pharmaceuticals, Inc. April July 28, 2017 Copyright Health Information Designs, LLC 29

30 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 07/28/2017 Initial publication and presentation to the DUR Board July 28, 2017 Copyright Health Information Designs, LLC 30

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