12/16/2015 Prior Authorization AETA BETTER HEALTH OF TEXAS MEDICAID 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 Aetna Better Health of Texas Medicaid (Bexar and Tarrant) at 1-844-275-1084. Please contact Aetna Better Health of Texas Medicaid (Bexar) at 1-800-248-7767 or Aetna Better Health of Texas Medicaid (Tarrant) at 1-800-306-8612 with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of Antipsychotics (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (specify drug) Quantity Frequency Strength Route of Administration Expected Length of therapy Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. Question Circle es or o 1. Is the incoming claim for a first generation antipsychotic? [If yes, then skip to question 5.] 2. Is the patient less than 3 years of age? [If yes, then no further questions.] 3. Is the patient greater than 5 years of age? [If yes, then skip to question 5.]
Question 4. Is the incoming request for aripiprazole or risperidone (excluding long-acting preparations)? Circle es or o 5. Does the patient have a diagnosis of insomnia in the last 365 days? [If yes, then skip to question 8.] 6. Does the patient have a diagnosis of major depressive disorder (MDD) in the last 365 days? [If no, then skip to question 8.] 7. Does the patient have 1 claim for an antidepressant agent included in Table C (below) in the last 60 days? [If yes, then skip to question 9.] 8. Does the patient have a diagnosis included in Table A or Table B (below) in the last 730 days? 9. Does the patient have 2 or more active claims for different antipsychotic agents in the last 180 days (excluding the incoming request)? [If no, then skip to question 11.] 10. Does the patient have 2 or more active claims for different antipsychotic agents in the last 30 days with at least 30 days supply remaining (excluding the incoming request)? 11. Is this request for a non-preferred drug? The Texas Medicaid Preferred Drug List can be found at txvendordrug.com 12. Has the patient had a treatment failure with a preferred drug within any subclass or a contraindication or allergic reaction to any preferred drugs? If yes, PLEASE LIST which drug, dates tried, and describe treatment failure, contraindication or allergic reaction experienced.
Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Table A ICD-9 Code 295 SCHIZOPHREIC DISORDERS 296.0 BIPOLOAR I DISORDER, SIGLE MAIC EPISODE 296.4 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC 296.5 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED 296.6 BIPOLOAR I DIOSRDER, MOST RECET EPISODE (OR CURRET) MIXED 296.7 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) USPECIFIED 296.80 BIPOLAR DISORDER, USPECIFIED 296.89 OTHER BIPOLAR DISORDERS 299.0 AUTISTIC DISORDER 296.99 OTHER SPECIFIED EPISODIC MOOD DISORDER 307.23 TOURETTE S DISORDER ICD-10 Code F20 SCHIZOPHREIA F31.0 BIPOLAR DISORDER, CURRET EPISODE HPOMAIC F31.1 BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES F31.6 BIPOLAR DISORDER, CURRET EPISODE MIXED F31.81 BIPOLAR II DISORDER F31.9 BIPOLAR DISORDER, USPECIFIED F34.8 OTHER PERSISTET MOOD DISORDER F84.0 AUTISTIC DISORDER F95.2 TOURETTE S DISORDER
Table B ICD-9 Code 312.81 CODUCT DISORDER, CHILDHOOD OSET 312.82 CODUCT DISORDER, ADOLESCET OSET 312.89 CODUCT DISORDER, OSET USPECIFIED 297 DELUSIOAL DISORDERS 297.0 PARAOID STATE, SIMPLE 297.1 DELUSIOAL DISORDER 297.2 PARAPHREIA 297.3 SHARED PSCHOTIC DISORDER 297.8 OTHER SPECIFIED PARAOID STATES 297.9 USPECIFIED PARAOID STATE 296.90 USPECIFIED EPISODIC MOOD DISORDER 298.9 USPECIFIED PSCHOSIS 299 PERVASIVE DEVELOPMETAL DISORDERS 299.1 CHILDHOOD DISITEGRATIVE DISORDER 299.8 OTHER SPECIFIED PERVASIVE DEVELOPMETAL DISORDER 299.9 USPECIFIED PERVASIVE DEVELOPMETAL DISORDER 312.34 ITERMITTET EXPLOSIVE DISORDER 313.81 OPPOSITIOAL DEFIAT DISORDER F91.1 CODUCT DISORDER, CHILDHOOD-OSET TPE F91.2 CODUCT DISORDER, ADOLESCET-OSET TPE F91.9 CODUCT DISORDER, USPECIFIED F22 F39 F09 F29 DELUSIOAL DISORDERS USPECIFIED MOOD DISORDER USPECIFIED METAL DISORDER DUE TO KOW PHSIOLOGICAL CODITIO USPECIFIED PSCHOSIS OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO F84.8 OTHER PERVASIVE DEVELOPMETAL DISORDERS F84.9 PERVASIVE DEVELOPMETAL DISORDER, USPECIFIED F63.81 ITERMITTET EXPLOSIVE DISORDER F91.3 OPPOSITIOAL DEFIAT DISORDER
Table C Required quantity: 1 Look back timeframe: 60 days APLEZI ER BRISDELLE BUPROPIO ER BUPROPIO BUPROPIO SR BUPROPIO XL CELEXA CITALOPRAM EFFEXOR EMSAM PATCH ESCITALOPRAM FLUOXETIE FLUVOXAMIIE FLUVOXAMIE ER FORFIVO XL KHEDEZLA ER MARPLA MIRTAZAPIE EFAZODOE OLEPTRO ER PAROXETIE PAROXETIE CR PAXIL PEXEVA PHEELZIE PRISTIQ ER PROZAC SERTRALIE TRALCPROMIE TRAZODOE VELAFAXIE VELAFAXIE ER VIIBRD WELLBUTRI WELLBUTRI SR ZOLOFT