Texas Prior Authorization Program Clinical Edit Criteria

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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 Note: Click the hyperlink to navigate directly to that section. Revision Notes Added a new section to specify the drugs requiring prior authorization Modified criteria logic and logic diagram to identify the steps that are executed manually In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the drug names and s pertinent to steps 3 and 5 of the logic diagram In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 4 and 7 of the logic diagram October 26, 2011 Copyright 2011 Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization XYREM 500 MG/ML ORAL SOLUTION October 26, 2011 Copyright 2011 Health Information Designs, LLC 2

3 Clinical Edit Criteria Logic 1. Is the request a phone call? [ ] Yes (Go to #2) [ ] No (Deny) 2. Is the client less than (<) 16 years of age? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have an active claim for? [ ] Yes (Deny) [ ] No (Go to #4) 4. Does the client have a diagnosis of alcohol or substance abuse in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #5) 5. Does the client have an active claim for a CNS depressant agent? [ ] Yes (Deny) [ ] No (Go to #6) 6. Is the requested dose per day less than or equal to ( ) 9 grams? [ ] Yes (Go to #7) [ ] No (Deny) 7. Does the client have a diagnosis of narcolepsy or cataplexy in the last 730 days? [ ] Yes (Approve 365 days) [ ] No (Go to #8) 8. Manual step Does the client have excessive daytime sleepiness, narcolepsy, or cataplexy? [ ] Yes (Approve 365 days) [ ] No (Deny) October 26, 2011 Copyright 2011 Health Information Designs, LLC 3

4 Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the request a phone call? Yes Is the client < 16 years of age? No Does the client have an active claim for? Yes Deny Request No Yes No Step 4 Deny Request Deny Request Does the client have a diagnosis of alcohol or substance abuse in the last 730 days? Yes Deny Request No Step 6 Step 5 Deny Request No Is the requested dose per day 9 grams for the client? No Does the client have an active claim for a CNS depressant agent? Yes Deny Request Yes Step 7 Step 8 (Manual) Approve Request (365 days) Yes Does the client have a diagnosis of narcolepsy or cataplexy in the last 730 days? No Does the client have excessive daytime sleepiness, narcolepsy, or cataplexy? No Deny Request Yes Approve Request (365 days) October 26, 2011 Copyright 2011 Health Information Designs, LLC 4

5 Clinical Edit Criteria Supporting Tables Step 3 (active claim for ) XYREM 500 MG/ML ORAL SOLUTION Step 4 (diagnosis of alcohol or substance abuse) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 303 ALCOHOL DEPENDENCE SYNDROME 3030 ACUTE ALCOHOLIC INTOXICATION AC ALCOHOL INTOX-UNSPEC AC ALCOHOL INTOX-CONTIN AC ALCOHOL INTOX-EPISOD AC ALCOHOL INTOX-REMISS 3039 OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE ALCOH DEP NEC/NOS-UNSPEC ALCOH DEP NEC/NOS-CONTIN ALCOH DEP NEC/NOS-EPISOD ALCOH DEP NEC/NOS-REMISS 304 DRUG DEPENDENCE 3040 OPIOID TYPE DEPENDENCE OPIOID DEPENDENCE-UNSPEC OPIOID DEPENDENCE-CONTIN OPIOID DEPENDENCE-EPISOD OPIOID DEPENDENCE-REMISS 3041 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE SEDATIVE,HYPNOTIC OR ANXIOLYTIC DEPENDENCE UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, CONTINUOUS SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION 3042 COCAINE DEPENDENCE October 26, 2011 Copyright 2011 Health Information Designs, LLC 5

6 ICD-9 Code Step 4 (diagnosis of alcohol or substance abuse) Description COCAINE DEPEND-UNSPEC COCAINE DEPEND-CONTIN COCAINE DEPEND-EPISODIC COCAINE DEPEND-REMISS 3043 CANNABIS DEPENDENCE CANNABIS DEPEND-UNSPEC CANNABIS DEPEND-CONTIN Required diagnosis: 1 Look back timeframe: 730 days CANNABIS DEPEND-EPISODIC CANNABIS DEPEND-REMISS 3044 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE AMPHETAMIN DEPEND-UNSPEC AMPHETAMIN DEPEND-CONTIN AMPHETAMIN DEPEND-EPISOD AMPHETAMIN DEPEND-REMISS 3045 HALLUCINOGEN DEPENDENCE HALLUCINOGEN DEP-UNSPEC HALLUCINOGEN DEP-CONTIN HALLUCINOGEN DEP-EPISOD HALLUCINOGEN DEP-REMISS 3046 OTHER SPECIFIED DRUG DEPENDENCE DRUG DEPEND NEC-UNSPEC DRUG DEPEND NEC-CONTIN DRUG DEPEND NEC-EPISODIC DRUG DEPEND NEC-IN REM 3047 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE OPIOID/OTHER DEP-UNSPEC OPIOID/OTHER DEP-CONTIN OPIOID/OTHER DEP-EPISOD OPIOID/OTHER DEP-REMISS 3048 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG COMB DRUG DEP NEC-UNSPEC COMB DRUG DEP NEC-CONTIN COMB DRUG DEP NEC-EPISOD COMB DRUG DEP NEC-REMISS 3049 UNSPECIFIED DRUG DEPENDENCE October 26, 2011 Copyright 2011 Health Information Designs, LLC 6

7 Step 4 (diagnosis of alcohol or substance abuse) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description DRUG DEPEND NOS-UNSPEC DRUG DEPEND NOS-CONTIN DRUG DEPEND NOS-EPISODIC DRUG DEPEND NOS-REMISS 305 NONDEPENDENT ABUSE OF DRUGS 3050 NONDEPENDENT ALCOHOL ABUSE ALCOHOL ABUSE-UNSPEC ALCOHOL ABUSE-CONTINUOUS ALCOHOL ABUSE-EPISODIC ALCOHOL ABUSE-IN REMISS 3052 NONDEPENDENT CANNABIS ABUSE CANNABIS ABUSE-UNSPEC CANNABIS ABUSE-CONTIN CANNABIS ABUSE-EPISODIC CANNABIS ABUSE-IN REMISS 3053 NONDEPENDENT HALLUCINOGEN ABUSE HALLUCINOG ABUSE-UNSPEC HALLUCINOG ABUSE-CONTIN HALLUCINOG ABUSE-EPISOD HALLUCINOG ABUSE-REMISS 3054 NONDEPENDENT SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC, ABUSE, CONTINUOUS SEDATIVE, HYPNOTIC, OR ANXIOLYTIC ABUSE, EPISODIC SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION 3055 NONDEPENDENT OPIOID ABUSE OPIOID ABUSE-UNSPEC OPIOID ABUSE-CONTINUOUS OPIOID ABUSE-EPISODIC OPIOID ABUSE-IN REMISS 3056 NONDEPENDENT COCAINE ABUSE COCAINE ABUSE-UNSPEC COCAINE ABUSE-CONTINUOUS COCAINE ABUSE-EPISODIC COCAINE ABUSE-IN REMISS October 26, 2011 Copyright 2011 Health Information Designs, LLC 7

8 ICD-9 Code 3057 Step 4 (diagnosis of alcohol or substance abuse) Description Required diagnosis: 1 Look back timeframe: 730 days NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE AMPHETAMINE ABUSE-UNSPEC AMPHETAMINE ABUSE-CONTIN AMPHETAMINE ABUSE-EPISOD AMPHETAMINE ABUSE-REMISS 3059 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE DRUG ABUSE NEC-UNSPEC DRUG ABUSE NEC-CONTIN DRUG ABUSE NEC-EPISODIC DRUG ABUSE NEC-IN REMISS ACETAMINOPHN-BUTALBITAL ACETAMINOPH-CAFF-DIHYDROCODEIN ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE ELIXIR ACETAMINOPHN-TRAMADOL ACTIQ 200 MCG LOZENGE ACTIQ 400 MCG LOZENGE ACTIQ 600 MCG LOZENGE ACTIQ 800 MCG LOZENGE ACTIQ 1,200 MCG LOZENGE ACTIQ 1,600 MCG LOZENGE ALAGESIC CAPSULES ALAGESIC LQ ORAL SOLUTION AMBIEN 5 MG TABLET AMBIEN 10 MG TABLET AMBIEN CR 6.25 MG TABLET AMBIEN CR 12.5 MG TABLET ATIVAN 0.5 MG TABLET October 26, 2011 Copyright 2011 Health Information Designs, LLC 8

9 ATIVAN 1 MG TABLET ATIVAN 2 MG TABLET ATIVAN 2 MG/ML VIAL ATIVAN 4 MG/ML VIAL AVINZA 30 MG CAPSULE AVINZA 45 MG CAPSULE AVINZA 60 MG CAPSULE AVINZA 75 MG CAPSULE AVINZA 90 MG CAPSULE AVINZA 120 MG CAPSULE BELLADONNA-OPIUM SUPP BELLADONNA-OPIUM SUPP BUPAP TABLET BUPRENEX 0.3 MG/ML AMPUL BUPRENORPHINE 2 MG TABLET SL BUPRENORPHINE 8 MG TABLET SL BUTALB-ACETAMIN-CAFF BUTALB-ACETAMIN-CAFF BUTALBIT-ACETAMINOPHEN-CAFF CP BUTALBITAL COMPOUND CAPSULE BUTALBITAL COMPOUND TABLET BUTALBITAL-ASA-CAFFEINE CAP BUTALBITAL-ASA-CAFFEINE TABLET BUTISOL SODIUM 30 MG/5 ML ELX BUTISOL SODIUM 30 MG TABLET BUTISOL SODIUM 50 MG TABLET BUTORPHANOL 1 MG/ML VIAL BUTORPHANOL 2 MG/ML VIAL BUTORPHANOL 10 MG/ML SPRAY BUTRANS 5 MCG/HR PATCH BUTRANS 10 MCG/HR PATCH BUTRANS 20 MCG/HR PATCH CAPITAL WITH CODEINE SUSP CARISOPRODOL CPD-CODEINE TAB CEPHADYN TABLET CHLORAL HYDRATE 500 MG/5 ML October 26, 2011 Copyright 2011 Health Information Designs, LLC 9

10 COCET PLUS TABLET COCET TABLET CODEINE SULFATE 30 MG TABLET CODEINE SULFATE 60 MG TABLET CO-GESIC TABLET DEMEROL 50 MG/ML AMPUL DEMEROL 50 MG/ML AMPUL DEMEROL 75 MG/1.5 ML AMPUL DEMEROL 100 MG/ML AMPUL DEMEROL 50 MG TABLET DEMEROL 100 MG TABLET DEMEROL 50 MG/ML VIAL DEMEROL 100 MG/ML VIAL DILAUDID 2 MG TABLET DILAUDID 4 MG TABLET DILAUDID 8 MG TABLET DILAUDID-5 1 MG/ML LIQUID DILAUDID-HP 10 MG/ML AMPUL DILAUDID-HP 10 MG/ML VIAL DILAUDID-HP 250 MG VIAL DOLGIC PLUS TABLET DOLOPHINE HCL 10 MG TABLET DORAL 15 MG TABLET DURAGESIC 12 MCG/HR PATCH DURAGESIC 25 MCG/HR PATCH DURAGESIC 50 MCG/HR PATCH DURAGESIC 75 MCG/HR PATCH DURAGESIC 100 MCG/HR PATCH EDLUAR 5 MG SL TABLET EDLUAR 10 MG SL TABLET EMBEDA MG CAPSULE EMBEDA MG CAPSULE EMBEDA 50-2 MG CAPSULE EMBEDA MG CAPSULE EMBEDA MG CAPSULE EMBEDA MG CAPSULE October 26, 2011 Copyright 2011 Health Information Designs, LLC 10

11 ENDOCET TABLET ENDOCET MG TABLET ENDOCET MG TABLET ENDOCET MG TABLET ENDOCET MG TABLET ENDODAN MG TABLET ESGIC PLUS CAPSULE ESGIC-PLUS MG TABLET ESTAZOLAM 1 MG TABLET ESTAZOLAM 2 MG TABLET ETH-OXYDOSE 20 MG/ML SOLUTION EXALGO ER 8 MG TABLET EXALGO ER 12 MG TABLET EXALGO ER 16 MG TABLET FENTANYL 12 MCG/HR PATCH FENTANYL 25 MCG/HR PATCH FENTANYL 50 MCG/HR PATCH FENTANYL 75 MCG/HR PATCH FENTANYL 100 MCG/HR PATCH FENTANYL CITRATE OTFC 200 MCG FENTANYL CITRATE OTFC 400 MCG FENTANYL CITRATE OTFC 600 MCG FENTANYL CITRATE OTFC 800 MCG FENTANYL CIT OTFC 1,200 MCG FENTANYL CIT OTFC 1,600 MCG FENTORA 100 MCG BUCCAL TABLET FENTORA 200 MCG BUCCAL TABLET FENTORA 400 MCG BUCCAL TABLET FENTORA 600 MCG BUCCAL TABLET FENTORA 800 MCG BUCCAL TABLET FIORICET MG TABLET FIORINAL MG CAPSULE FLURAZEPAM 15 MG CAPSULE FLURAZEPAM 30 MG CAPSULE HALCION 0.25 MG TABLET HYCET 7.5 MG-325 MG/15 ML SOL October 26, 2011 Copyright 2011 Health Information Designs, LLC 11

12 HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPH HYDROCODON-ACETAMINOPHEN HYDROCODON-ACETAMINOPHEN HYDROCODON-ACETAMINOPHEN HYDROCODON-ACETAMINOPHN HYDROCODON-ACETAMINOPHN HYDROCODON-ACETAMINOPHN HYDROCODON-ACETAMINOPHN HYDROCODON-ACETAMINOPHN HYDROCODON-ACETAMINOPHN HYDROCODONE-ACETAMINOPHEN SOLN HYDROCODONE BT-IBUPROFEN TAB HYDROGESIC MG CAPSULE HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE 2 MG TABLET HYDROMORPHONE 4 MG TABLET HYDROMORPHONE 8 MG TABLET HYDROMORPHONE 10 MG/ML VIAL IBUDONE MG TABLET IBUDONE MG TABLET INFUMORPH 10 MG/ML AMPUL P-F INFUMORPH 25 MG/ML AMPUL P-F KADIAN ER 10 MG CAPSULE KADIAN ER 20 MG CAPSULE KADIAN ER 30 MG CAPSULE KADIAN ER 50 MG CAPSULE KADIAN ER 60 MG CAPSULE KADIAN ER 80 MG CAPSULE KADIAN ER 100 MG CAPSULE KADIAN ER 200 MG CAPSULE LEVORPHANOL 2 MG TABLET LORAZEPAM 2 MG/ML ORAL CONCENT October 26, 2011 Copyright 2011 Health Information Designs, LLC 12

13 LORAZEPAM 0.5 MG TABLET LORAZEPAM 1 MG TABLET LORAZEPAM 2 MG TABLET LORAZEPAM 2 MG/ML VIAL LORAZEPAM 4 MG/ML VIAL LORAZEPAM INTENSOL 2 MG/ML LORCET TABLET LORCET PLUS TABLET LORTAB TABLET LORTAB TABLET LORTAB TABLET LORTAB ELIXIR LUNESTA 1 MG TABLET LUNESTA 2 MG TABLET LUNESTA 3 MG TABLET MEPERIDINE 50 MG/5 ML SOLUTION MEPERIDINE 50 MG TABLET MEPERIDINE 100 MG TABLET MEPERIDINE 25 MG/ML VIAL MEPERIDINE 50 MG/ML VIAL MEPERIDINE 100 MG/ML VIAL MEPERITAB 50 MG TABLET MEPERITAB 100 MG TABLET METHADONE 10 MG/ML ORAL CONC METHADONE 5 MG/5 ML SOLUTION METHADONE 10 MG/5 ML SOLUTION METHADONE 40 MG TABLET DISPR METHADONE HCL 5 MG TABLET METHADONE HCL 10 MG TABLET METHADONE INTENSOL 10 MG/ML METHADOSE 10 MG/ML ORAL CONC METHADOSE 10 MG TABLET METHADOSE 40 MG TABLET DISPR MORPHINE 15 MG/ML VIAL MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULF 20 MG/5 ML SOLN October 26, 2011 Copyright 2011 Health Information Designs, LLC 13

14 MORPHINE SULF 100 MG/5 ML SOLN MORPHINE SULF CR 15 MG TABLET MORPHINE SULF CR 30 MG TABLET MORPHINE SULF CR 60 MG TABLET MORPHINE SULF CR 100 MG TABLET MORPHINE SULF CR 200 MG TABLET MORPHINE SULF ER 15 MG TABLET MORPHINE SULF ER 30 MG TABLET MORPHINE SULF ER 60 MG TABLET MORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE 50 MG/ML VIAL MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE IR 30 MG TAB MS CONTIN 15 MG TABLET MS CONTIN 60 MG TABLET MS CONTIN 100 MG TABLET MS CONTIN 200 MG TABLET MS CONTIN CR 30 MG TABLET NALBUPHINE 10 MG/ML AMPUL NALBUPHINE 200 MG/10 ML VIAL NEMBUTAL SODIUM 50 MG/ML VIA NORCO TABLET NUCYNTA 50 MG TABLET NUCYNTA 75 MG TABLET NUCYNTA 100 MG TABLET ONSOLIS 200 MCG SOLUBLE FILM ONSOLIS 400 MCG SOLUBLE FILM ONSOLIS 600 MCG SOLUBLE FILM ONSOLIS 800 MCG SOLUBLE FILM ONSOLIS 1,200 MCG SOLUBLE FILM OPANA 5 MG TABLET OPANA 10 MG TABLET OPANA ER 5 MG TABLET OPANA ER 7.5 MG TABLET OPANA ER 10 MG TABLET October 26, 2011 Copyright 2011 Health Information Designs, LLC 14

15 OPANA ER 15 MG TABLET OPANA ER 20 MG TABLET OPANA ER 30 MG TABLET OPANA ER 40 MG TABLET OPIUM TINCTURE 10 MG/ML ORAMORPH SR 15 MG TABLET ORAMORPH SR 30 MG TABLET ORAMORPH SR 60 MG TABLET ORAMORPH SR 100 MG TABLET ORBIVAN CAPSULE OXYCODON-ACETAMINOPHEN OXYCODON-ACETAMINOPHEN OXYCODON-ACETAMINOPHEN OXYCODONE CONC 20 MG/ML SOLN OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL 5 MG/5 ML SOL OXYCODONE HCL 20 MG/ML SOLN OXYCODONE HCL 5 MG TABLET OXYCODONE HCL 10 MG TABLET OXYCODONE HCL 15 MG TABLET OXYCODONE HCL 20 MG TABLET OXYCODONE HCL 30 MG TABLET OXYCODONE HCL CR 80 MG TABLET OXYCODONE HCL ER 80 MG TABLET OXYCODONE-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN OXYCODONE-ACETAMINOPHEN OXYCODONE-ASA TAB OXYCODONE-IBUPROFEN TAB OXYCONTIN 10 MG TABLET OXYCONTIN 15 MG TABLET OXYCONTIN 20 MG TABLET OXYCONTIN 30 MG TABLET OXYCONTIN 40 MG TABLET OXYCONTIN 60 MG TABLET October 26, 2011 Copyright 2011 Health Information Designs, LLC 15

16 OXYCONTIN 80 MG TABLET OXYMORPHONE HCL 5 MG TABLET OXYMORPHONE HCL 10 MG TABLET PANLOR DC CAPSULE PANLOR SS TABLET PENTAZOCIN-ACETAMINOPHN PENTAZOCINE-NALOXONE TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCOCET MG TABLET PERCODAN 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 PHRENILIN FORTE CAPSULE POLYGESIC 5/500 CAPSULE PRIMALEV MG TABLET PRIMLEV MG TABLET PRIMLEV MG TABLET PRIMLEV MG TABLET PROMACET MG TABLET PROPOXYPH-ACETAMINOPHEN REPREXAIN MG TABLET REPREXAIN MG TABLET REPREXAIN MG TABLET October 26, 2011 Copyright 2011 Health Information Designs, LLC 16

17 REPREXAIN MG TABLET RESTORIL 7.5 MG CAPSULE RESTORIL 15 MG CAPSULE RESTORIL 22.5 MG CAPSULE RESTORIL 30 MG CAPSULE ROXICET CAPLET ROXICET ORAL SOLUTION ROXICET TABLET ROXICODONE 5 MG/5 ML SOLUTION ROXICODONE 5 MG TABLET ROXICODONE 15 MG TABLET ROXICODONE 30 MG TABLET ROXICODONE INTENSOL 20 MG/ML ROZEREM 8 MG TABLET RYBIX ODT 50 MG TABLET RYZOLT ER 100 MG TABLET RYZOLT ER 200 MG TABLET RYZOLT ER 300 MG TABLET SECONAL SODIUM 100 MG CAPSULE SEDAPAP TABLET SOMNOTE 500 MG SOFTGEL SONATA 5 MG CAPSULE SONATA 10 MG CAPSULE SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM SUBOXONE 2 MG-0.5 MG TABLET SL SUBOXONE 8 MG-2 MG TABLET SL SUBUTEX 2 MG TABLET SL SUBUTEX 8 MG TABLET SL TALACEN CAPLET TALWIN 30 MG/ML VIAL TALWIN NX TABLET TEMAZEPAM 7.5 MG CAPSULE TEMAZEPAM 15 MG CAPSULE TEMAZEPAM 22.5 MG CAPSULE TEMAZEPAM 30 MG CAPSULE October 26, 2011 Copyright 2011 Health Information Designs, LLC 17

18 TRAMADOL HCL 50 MG TABLET TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER 200 MG TABLET TRAMADOL-ACETAMINOPHN TREZIX CAPSULE TRIAZOLAM 0.25 MG TABLET TRIAZOLAM MG TABLET TYLENOL WITH CODEINE #3 TABLET TYLENOL WITH CODEINE #4 TABLET TYLOX CAPSULE ULTRACET TABLET ULTRAM 50 MG TABLET ULTRAM ER 100 MG TABLET ULTRAM ER 200 MG TABLET ULTRAM ER 300 MG TABLET VICODIN TABLET VICODIN ES MG TABLET VICODIN HP TABLET VICOPROFEN MG TAB XODOL TABLET XODOL MG TABLET XODOL TABLET XOLOX MG TABLET ZALEPLON 5 MG CAPSULE ZALEPLON 10 MG CAPSULE ZAMICET SOLUTION ZEBUTAL CAPSULE ZERLOR TABLET ZOLPIDEM TART ER 12.5 MG TAB ZOLPIDEM TARTRATE 5 MG TABLET ZOLPIDEM TARTRATE 10 MG TABLET ZOLPIMIST 5 MG ORAL SPRAY ZOLVIT 10 MG-300 MG/15 ML SOL ZYDONE MG TABLET ZYDONE MG TABLET ZYDONE MG TABLET October 26, 2011 Copyright 2011 Health Information Designs, LLC 18

19 ICD-9 Code Step 7 (diagnosis of narcolepsy or cataplexy) Description Required diagnosis: 1 Look back timeframe: 730 days 347 CATAPLEXY AND NARCOLEPSY 3470 NARCOLEPSY NARCOLEPSY, WITHOUT CATAPLEXY NARCOLEPSY,WITH CATAPLEXY 3471 NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE,WITH CATAPLEXY October 26, 2011 Copyright 2011 Health Information Designs, LLC 19

20 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 03/09/2011 Initial publication and posting to website 10/26/2011 Added a new section to specify the drugs requiring prior authorization Modified criteria logic and logic diagram to identify the steps that are executed manually In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the drug names and s pertinent to steps 3 and 5 of the logic diagram In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 4 and 7 of the logic diagram October 26, 2011 Copyright 2011 Health Information Designs, LLC 20

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