Drugs Requiring Prior Authorization Label Name ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE CAPSULE ACETAMINOPHEN/CODEINE SOLUTION ACETAMINOPHEN/CODEINE TABLET ASCOMP/CODEINE CAPSULE BUTALBITAL/CAFFEINE/ACETAMINOPHEN/CODEINE BUTALBITAL/CAFFEINE/ASPIRIN/CODEINE CAPSULE BUTRANS DISC CAPITAL/CODEINE SUSPENSION CODEINE SULFATE TABLET DEMEROL INJECTION DEMEROL TABLET DILAUDID TABLET DILAUDID-5 LIQUID DILAUDID-HP INJECTION DOLOPHINE TABLET EMBEDA CASULE ENDOCET TABLET EXALGO TABLET FIORICET/CODEINE CAPSULE FIORINAL/CODEINE CAPSULE HYDROCODONE/ACETAMINOPHEN SOLUTION HYDROCODONE/ACETAMINOPHEN TABLET HYDROCODONE/IBUPROFEN TABLET HYDROMORPHONE ER TABLET HYDROMORPHONE INJECTION HYDROMORPHONE LIQUID HYDROMORPHONE SOLUTION HYDROMORPHONE SUPPOSITORY HYDROMORPHONE TABLET HYSINGLA ER TABLET IBUDONE TABLET KADIAN ER CAPSULE LORCET HD TABLET LORCET PLUS TABLET LORTAB TABLET MEPERIDINE INJECTION MEPERITAB TABLET METHADONE CONCENTRATE 06/01/
METHADONE SOLUTION METHADONE TABLET METHADOSE CONCENTRATE METHADOSE TABLET METHADOSE SF CONCENTRATE MORPHINE SULFATE ER CAPSULE MORPHINE SULFATE ER TABLET MORPHINE SULFATE INJECTION MORPHINE SULFATE SOLUTION MORPHINE SULFATE TABLET MS CONTIN CR TABLET NORCO TABLET NUCYNTA TABLET NUCYNTA ER TABLET OPANA TABLET OPANA ER TABLET OXYCODONE CAPSULE OXYCODONE CONCENTRATE OXYCODONE SOLUTION OXYCODONE TABLET OXYCODONE/ACETAMINOPHEN TABLET OXYCODONE/ASPIRIN TABLET OXYCODONE/IBUPROFEN TABLET OXYMORPHONE TABLET HCL OXYMORPHONE ER TABLET PERCOCET TABLET REPREXAIN TABLET ROXICODONE TABLET TYLENOL/CODEINE TABLET VICODIN TABLET VICODIN ES TABLET VICODIN HP TABLET XARTEMIS XR TABLET XODOL TABLET XOLOX TABLET XTAMPZA ER CAPSULE 06/01/
Clinical Edit Criteria Logic 1. Does the client have THREE (3) or more prescribers of opiates in the last 60 () (Go to #2) 2. Does the client have at least a 150-day supply of opiates in the last 60 (Go to #3) (Approve 180 Days) 3. Does the client have EIGHT (8) or more opiate claims in the last 60 () (Go to #4) 4. Does the client have THREE (3) or more opiate dispensing pharmacies in the last 60 () (Approve 180 Days) 06/01/
Clinical Edit Criteria Logic Diagram Step 1: Does the client have 3 or more prescribers of opiates in the last 60 Step 2: Does the client have at least a 150- day supply of opiates in the last 60 Approve for 180 days Step 3: Does the client have 8 or more opiate claims in the last 60 Step 4: Does the client have 3 or more opiate dispensing pharmacies in the last 60 Approve for 180 days 06/01/
Clinical Edit Criteria Supporting Tables Step 2 and 3 Refer to the table above Drugs Requiring Prior Authorization Clinical Edit Criteria References 1. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic n-cancer Pain: Part 2 Guidance. Pain Physician, 2012 Jul; 15 (3 Suppl):S67-116. 2. Cepeda MS, Fife D, Chow W, Mastrogiovanni G, Henderson SC. Opioid shopping behavior: how often, how soon, which drugs and what payment method. J Clin Pharmacol, 2013 Jan;53(1):112-7. 3. Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician, 2012 Jul;15(3 Suppl):ES9-38. 4. Chapman, Richard C. Opioid Pharmacotherapy for Chronic ncancer Pain: The American Experience. Korean J Pain, 2013 Jan;26(1):3-13. 5. Centers for Medicare and Medicaid Services. Drug Diversion in the Medicaid Program: State Strategies for Reducing Prescription Drug Diversion in Medicaid. January 2012. Available at http://www.cms.gov/medicare- Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/downloads/drugdiversion.pdf. 6. National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention. Prescription Painkiller Overdoses. vember 2011. Available at http://www.cdc.gov/homeandrecreationalsafety/pdf/policyimpact-prescriptionpainkillerod.pdf. 7. National Institute on Drug Abuse. DrugFacts: Drug-related Hospital Emergency Room Visits. May 2011. Available at http://www.drugabuse.gov/publications/drugfacts/drug-related-hospital-emergency-room-visits. 8. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; February 2013. Available at http://cp.gsm.com. Accessed on March 12, 2013. 9. 2013 ICD-9-CM Diagnosis Codes, Volume 1, 2012. Available at http://www.icd9data.com/. Accessed on March 11, 2013. 10. 2015 ICD-10-CM Diagnosis Codes. 2015. Available at www.icd10data.com. Accessed on April 3, 2015. 11. American Medical Association data files. 2015 ICD-9-CM Diagnosis Codes. Available at www.commerce.ama-assn.org. 12. American Medical Association data files. 2015 ICD-10-CM Diagnosis Codes. Available at www.commerce.ama-assn.org. Publication History Publication Date tes 4/10/12 Initial publication and posting to website New medications added 11/17/16 Updated date Added additional Clinical Edit Criteria References Updated drug list included in edit Removed drugs included in a separate, stricter 6/1/ clinical edit including Fentanyl Agents, Oxycontin, and Carisoprodol (Compounds) 06/01/