Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Medications

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1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Medications Clinical Edit Information Included in this Document IR Formulations 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) References: clinical publications and sources relevant to this clinical edit ER Formulations 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) References: clinical publications and sources relevant to this clinical edit March 27, 2015 Copyright Health Information Designs, LLC 1

2 Non-stimulant Formulations (Except Clonidine ER) Clonidine ER 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) References: clinical publications and sources relevant to this clinical edit 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) References: clinical publications and sources relevant to this clinical edit Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated to include Evekeo GCNs September 2, 2015 Copyright Health Information Designs, LLC 2

3 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Drugs Requiring Prior Authorization Label Name Drug Requiring Prior Authorization GCN ADDERALL 5MG TABLET ADDERALL 7.5MG TABLET ADDERALL 10MG TABLET ADDERALL 12.5MG TABLET ADDERALL 15MG TABLET ADDERALL 20MG TABLET ADDERALL 30MG TABLET MG TABLET 7.5MG TABLET 10MG TABLET 12.5MG TABLET 15MG TABLET 20MG TABLET 30MG TABLET DESOXYN 5MG TABLET DEXMETHYLPHENIDATE 2.5MG TABLET DEXMETHYLPHENIDATE 5MG TABLET DEXMETHYLPHENIDATE 10MG TABLET DEXTROAMPHETAMINE 5MG TABLET DEXTROAMPHETAMINE 10MG TABLET DEXTROAMPHETAMINE 5MG/5ML SOLUTION EVEKEO 5MG TABLET EVEKEO 10MG TABLET FOCALIN 2.5MG TABLET FOCALIN 5MG TABLET FOCALIN 10MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 3

4 Drug Requiring Prior Authorization Label Name GCN METHAMPHETAMINE 5MG TABLET METHYLIN 2.5MG CHEWABLE TABLET METHYLIN 5MG CHEWABLE TABLET METHYLIN 10MG CHEWABLE TABLET METHYLIN 5MG/5ML SOLUTION METHYLIN 10MG/5ML SOLUTION METHYLPHENIDATE 5MG/5ML SOL METHYLPHENIDATE 10MG/5ML SOL METHYLPHENIDATE 5MG TABLET METHYLPHENIDATE 10MG TABLET METHYLPHENIDATE 20MG TABLET PROCENTRA 5MG/5ML SOLUTION RITALIN 5MG TABLET RITALIN 10MG TABLET RITALIN 20MG TABLET ZENZEDI 2.5MG TABLET ZENZEDI 5MG TABLET ZENZEDI 7.5MG TABLET ZENZEDI 10MG TABLET ZENZEDI 15MG TABLET ZENZEDI 20MG TABLET ZENZEDI 30MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 4

5 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Clinical Edit Criteria Logic 1. Is the client less than (<) 3 years of age? [] Yes Deny [] No Go to #2 2. Does the client have a history of substance abuse in the last 365 days? [] Yes Deny [] No Go to #3 3. Is the request for greater than (>) the Texas Department of Family and Protective Services (DFPS) maximum recommended daily dose? [] Yes Deny [] No Go to #4 4. Does the client have a paid claim for another IR stimulant in the past 14 days? [] Yes Deny [] No Go to #5 5. Is the client less than (<) 6 years of age? [] Yes Go to #6 [] No Go to #7 6. Is the request for amphetamine salts, dextroamphetamine, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi? [] Yes Approve (365 days) [] No Deny 7. Is the client greater than or equal to ( ) 19 years of age? [] Yes Go to #8 [] No Approve (365 days) 8. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [] Yes Approve (365 days) [] No Go to #9 9. Does the client have a diagnosis of narcolepsy in the past 730 days? [] Yes Go to #10 [] No Deny 10. Is the request for dexmethylphenidate or methamphetamine? [] Yes Deny [] No Approve (365 days) September 2, 2015 Copyright Health Information Designs, LLC 5

6 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Clinical Edit Criteria Logic Diagram The IR Formulations Clinical Edit Criteria Logic Diagram is shown on the following page. September 2, 2015 Copyright Health Information Designs, LLC 6

7 No No Yes No Yes Yes Yes Yes No No Texas Prior Authorization Program Clinical Edits Step 1 Step 2 Step 3 Step 4 Is the client less than 3 years of age? Does the client have a history of substance abuse in the last 365 days? Is the request for greater than the TX DFPS maximum daily dose? Does the client have a paid claim for another IR stimulant in the past 14 days? Deny Deny Deny Deny Step 5 Is the client less than 6 years of age? Step 6 Is the request for amphetamine salts, dextroamphetamine, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi? Step 7 Is the client greater than or equal to 19 years of age? Approve (365 days) Step 10 Step 9 Step 8 Deny Yes Is the request for dexmethylphenidate or methamphetamine? Yes Does the client have a diagnosis of narcolepsy in the last 730 days? No Does the client have a diagnosis of ADD/ADHD in the last 730 days? Approve (365 days) Approve (365 days) Deny September 2, 2015 Copyright Health Information Designs, LLC 7

8 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Clinical Edit Criteria Supporting Tables Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses ICD-9 Code Description OPIOID DEPENDENCE-UNSPEC OPIOID DEPENDENCE-CONTIN OPIOID DEPENDENCE-EPISOD OPIOID DEPENDENCE-REMISS 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 COCAINE DEPEND-UNSPEC COCAINE DEPEND-CONTIN COCAINE DEPEND-EPISODIC COCAINE DEPEND-REMISS CANNABIS DEPEND-UNSPEC CANNABIS DEPEND-CONTIN CANNABIS DEPEND-EPISODIC CANNABIS DEPEND-REMISS AMPHETAMIN DEPEND-UNSPEC AMPHETAMIN DEPEND-CONTIN AMPHETAMIN DEPEND-EPISOD AMPHETAMIN DEPEND-REMISS HALLUCINOGEN DEP-UNSPEC HALLUCINOGEN DEP-CONTIN HALLUCINOGEN DEP-EPISOD HALLUCINOGEN DEP-REMISS DRUG DEPEND NEC-UNSPEC DRUG DEPEND NEC-CONTIN DRUG DEPEND NEC-EPISODIC September 2, 2015 Copyright Health Information Designs, LLC 8

9 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses DRUG DEPEND NEC-IN REM OPIOID/OTHER DEP-UNSPEC OPIOID/OTHER DEP-CONTIN OPIOID/OTHER DEP-EPISOD OPIOID/OTHER DEP-REMISS COMB DRUG DEP NEC-UNSPEC COMB DRUG DEP NEC-CONTIN COMB DRUG DEP NEC-EPISOD COMB DRUG DEP NEC-REMISS DRUG DEPEND NOS-UNSPEC DRUG DEPEND NOS-CONTIN DRUG DEPEND NOS-EPISODIC DRUG DEPEND NOS-REMISS ALCOHOL ABUSE-UNSPEC ALCOHOL ABUSE-CONTINUOUS ALCOHOL ABUSE-EPISODIC ALCOHOL ABUSE-IN REMISS CANNABIS ABUSE-UNSPEC CANNABIS ABUSE-CONTIN CANNABIS ABUSE-EPISODIC CANNABIS ABUSE-IN REMISS HALLUCINOG ABUSE-UNSPEC HALLUCINOG ABUSE-CONTIN HALLUCINOG ABUSE-EPISOD HALLUCINOG ABUSE-REMISS 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 OPIOID ABUSE-UNSPEC OPIOID ABUSE-CONTINUOUS OPIOID ABUSE-EPISODIC OPIOID ABUSE-IN REMISS COCAINE ABUSE-UNSPEC COCAINE ABUSE-CONTINUOUS COCAINE ABUSE-EPISODIC September 2, 2015 Copyright Health Information Designs, LLC 9

10 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses COCAINE ABUSE-IN REMISS AMPHETAMINE ABUSE-UNSPEC AMPHETAMINE ABUSE-CONTIN AMPHETAMINE ABUSE-EPISOD AMPHETAMINE ABUSE-REMISS DRUG ABUSE NEC-UNSPEC DRUG ABUSE NEC-CONTIN DRUG ABUSE NEC-EPISODIC DRUG ABUSE NEC-IN REMISS ICD-10 Code F1010 F10120 F10121 F10129 F1014 F10150 F10151 F10159 F10180 F10181 F10182 F10188 F1019 F1020 F10220 F10221 F10229 F10230 F10231 F10232 F10239 F1024 Description ALCOHOL ABUSE UNCOMPLICATED ALCOHOL ABUSE WITH INTOXICATION UNCOMPLICATED ALCOHOL ABUSE WITH INTOXICATION DELIRIUM ALCOHOL ABUSE WITH INTOXICATION UNSPECIFIED ALCOHOL ABUSE WITH ALCOHOL-INDUCED MOOD ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC WITH DELUSIONS ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC WITH HALLUCINATIONS ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC UNSPECIFIED ALCOHOL ABUSE WITH ALCOHOL-INDUCED ANXIETY ALCOHOL ABUSE WITH ALCOHOL-INDUCED SEXUAL DYSFUNCTION ALCOHOL ABUSE WITH ALCOHOL-INDUCED SLEEP ALCOHOL ABUSE WITH OTHER ALCOHOL-INDUCED ALCOHOL ABUSE WITH UNSPECIFIED ALCOHOL-INDUCED ALCOHOL DEPENDENCE UNCOMPLICATED ALCOHOL DEPENDENCE WITH INTOXICATION UNCOMPLICATED ALCOHOL DEPENDENCE WITH INTOXICATION DELIRIUM ALCOHOL DEPENDENCE WITH INTOXICATION UNSPECIFIED ALCOHOL DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED ALCOHOL DEPENDENCE WITH WITHDRAWAL DELIRIUM ALCOHOL DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE ALCOHOL DEPENDENCE WITH WITHDRAWAL UNSPECIFIED ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED MOOD September 2, 2015 Copyright Health Information Designs, LLC 10

11 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses F10250 F10251 F10259 F1026 F1027 F10280 F10281 F10282 F10288 F1029 F1110 F11120 F11121 F11122 F11129 F1114 F11150 F11151 F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11220 F11221 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC WITH DELUSIONS ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC WITH HALLUCINATIONS ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC UNSPECIFIED ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PERSISTING AMNESTIC ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PERSISTING DEMENTIA ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED ANXIETY ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED SEXUAL DYSFUNCTION ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED SLEEP ALCOHOL DEPENDENCE WITH OTHER ALCOHOL-INDUCED ALCOHOL DEPENDENCE WITH UNSPECIFIED ALCOHOL-INDUCED OPIOID ABUSE UNCOMPLICATED OPIOID ABUSE WITH INTOXICATION UNCOMPLICATED OPIOID ABUSE WITH INTOXICATION DELIRIUM OPIOID ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OPIOID ABUSE WITH INTOXICATION UNSPECIFIED OPIOID ABUSE WITH OPIOID-INDUCED MOOD OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC WITH DELUSIONS OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC WITH HALLUCINATIONS OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC UNSPECIFIED OPIOID ABUSE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION OPIOID ABUSE WITH OPIOID-INDUCED SLEEP OPIOID ABUSE WITH OTHER OPIOID-INDUCED OPIOID ABUSE WITH UNSPECIFIED OPIOID-INDUCED OPIOID DEPENDENCE, UNCOMPLICATED OPIOID DEPENDENCE, IN REMISSION OPIOID DEPENDENCE WITH INTOXICATION UNCOMPLICATED OPIOID DEPENDENCE WITH INTOXICATION DELIRIUM September 2, 2015 Copyright Health Information Designs, LLC 11

12 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses F11222 F11229 F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288 F1129 F1210 F12120 F12121 F12122 F12129 F12150 F12151 F12159 F12180 F12188 F1219 F1220 F1221 F12220 F12221 F12222 F12229 F12250 OPIOID DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OPIOID DEPENDENCE WITH INTOXICATION UNSPECIFIED OPIOID DEPENDENCE WITH WITHDRAWAL OPIOID DEPENDENCE WITH OPIOID-INDUCED MOOD OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC WITH DELUSIONS OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC WITH HALLUCINATIONS OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC UNSPECIFIED OPIOID DEPENDENCE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION OPIOID DEPENDENCE WITH OPIOID-INDUCED SLEEP OPIOID DEPENDENCE WITH OTHER OPIOID-INDUCED OPIOID DEPENDENCE WITH UNSPECIFIED OPIOID-INDUCED CANNABIS ABUSE UNCOMPLICATED CANNABIS ABUSE WITH INTOXICATION UNCOMPLICATED CANNABIS ABUSE WITH INTOXICATION DELIRIUM CANNABIS ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE CANNABIS ABUSE WITH INTOXICATION UNSPECIFIED CANNABIS ABUSE WITH PSYCHOTIC WITH DELUSIONS CANNABIS ABUSE WITH PSYCHOTIC WITH HALLUCINATIONS CANNABIS ABUSE WITH PSYCHOTIC UNSPECIFIED CANNABIS ABUSE WITH CANNABIS-INDUCED ANXIETY CANNABIS ABUSE WITH OTHER CANNABIS-INDUCED CANNABIS ABUSE WITH UNSPECIFIED CANNABIS-INDUCED CANNABIS DEPENDENCE, UNCOMPLICATED CANNABIS DEPENDENCE, IN REMISSION CANNABIS DEPENDENCE WITH INTOXICATION UNCOMPLICATED CANNABIS DEPENDENCE WITH INTOXICATION DELIRIUM CANNABIS DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE CANNABIS DEPENDENCE WITH INTOXICATION UNSPECIFIED CANNABIS DEPENDENCE WITH PSYCHOTIC WITH DELUSIONS September 2, 2015 Copyright Health Information Designs, LLC 12

13 F12251 F12259 F12280 F12288 F1229 F1310 F13120 F13121 F13129 F1314 F13150 F13151 F13159 F13180 F13181 F13182 F13188 F1319 F1320 F1321 F13220 F13221 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses CANNABIS DEPENDENCE WITH PSYCHOTIC WITH HALLUCINATIONS CANNABIS DEPENDENCE WITH PSYCHOTIC UNSPECIFIED CANNABIS DEPENDENCE WITH CANNABIS-INDUCED ANXIETY CANNABIS DEPENDENCE WITH OTHER CANNABIS-INDUCED CANNABIS DEPENDENCE WITH UNSPECIFIED CANNABIS-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION DELIRIUM SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED MOOD SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC WITH DELUSIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC WITH HALLUCINATIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED ANXIETY SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEXUAL DYSFUNCTION SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SLEEP SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH OTHER SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE IN REMISSION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION DELIRIUM September 2, 2015 Copyright Health Information Designs, LLC 13

14 F13229 F13230 F13231 F13232 F13239 F1324 F13250 F13251 F13259 F1326 F1327 F13280 F13281 F13282 F13288 F1329 F1410 F14120 F14121 F14122 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL DELIRIUM SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED MOOD SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC WITH HALLUCINATIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING AMNESTIC SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING DEMENTIA SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED ANXIETY SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEXUAL DYSFUNCTION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SLEEP SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH OTHER SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED COCAINE ABUSE UNCOMPLICATED COCAINE ABUSE WITH INTOXICATION UNCOMPLICATED COCAINE ABUSE WITH INTOXICATION WITH DELIRIUM COCAINE ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE September 2, 2015 Copyright Health Information Designs, LLC 14

15 F14129 F1414 F14150 F14151 F14159 F14180 F14181 F14182 F14188 F1419 F1420 F14220 F14221 F14222 F14229 F1423 F1424 F14250 F14251 F14259 F14280 F14281 F14282 F14288 F1429 F1510 F15120 F15121 F15122 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses COCAINE ABUSE WITH INTOXICATION UNSPECIFIED COCAINE ABUSE WITH COCAINE-INDUCED MOOD COCAINE ABUSE WITH COCAINE-INDUCED PSYCHOTIC WITH DELUSIONS COCAINE ABUSE WITH COCAINE-INDUCED PSYCHOTIC WITH HALLUCINATIONS COCAINE ABUSE WITH COCAINE-INDUCED PSYCHOTIC UNSPECIFIED COCAINE ABUSE WITH COCAINE-INDUCED ANXIETY COCAINE ABUSE WITH COCAINE-INDUCED SEXUAL DYSFUNCTION COCAINE ABUSE WITH COCAINE-INDUCED SLEEP COCAINE ABUSE WITH OTHER COCAINE-INDUCED COCAINE ABUSE WITH UNSPECIFIED COCAINE-INDUCED COCAINE DEPENDENCE UNCOMPLICATED COCAINE DEPENDENCE WITH INTOXICATION UNCOMPLICATED COCAINE DEPENDENCE WITH INTOXICATION DELIRIUM COCAINE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE COCAINE DEPENDENCE WITH INTOXICATION UNSPECIFIED COCAINE DEPENDENCE WITH WITHDRAWAL COCAINE DEPENDENCE WITH COCAINE-INDUCED MOOD COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC WITH DELUSIONS COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC WITH HALLUCINATIONS COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC UNSPECIFIED COCAINE DEPENDENCE WITH COCAINE-INDUCED ANXIETY COCAINE DEPENDENCE WITH COCAINE-INDUCED SEXUAL DYSFUNCTION COCAINE DEPENDENCE WITH COCAINE-INDUCED SLEEP COCAINE DEPENDENCE WITH OTHER COCAINE-INDUCED COCAINE DEPENDENCE WITH UNSPECIFIED COCAINE-INDUCED OTHER STIMULANT ABUSE UNCOMPLICATED OTHER STIMULANT ABUSE WITH INTOXICATION UNCOMPLICATED OTHER STIMULANT ABUSE WITH INTOXICATION DELIRIUM OTHER STIMULANT ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE September 2, 2015 Copyright Health Information Designs, LLC 15

16 F15129 F1514 F15150 F15151 F15159 F15180 F15181 F15182 F15188 F1519 F1520 F15220 F15221 F15222 F15229 F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282 F15288 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses OTHER STIMULANT ABUSE WITH INTOXICATION UNSPECIFIED OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED MOOD OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED PSYCHOTIC WITH DELUSIONS OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED PSYCHOTIC UNSPECIFIED OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED ANXIETY OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED SEXUAL DYSFUNCTION OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED SLEEP OTHER STIMULANT ABUSE WITH OTHER STIMULANT-INDUCED OTHER STIMULANT ABUSE WITH UNSPECIFIED STIMULANT-INDUCED OTHER STIMULANT DEPENDENCE UNCOMPLICATED OTHER STIMULANT DEPENDENCE WITH INTOXICATION UNCOMPLICATED OTHER STIMULANT DEPENDENCE WITH INTOXICATION DELIRIUM OTHER STIMULANT DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OTHER STIMULANT DEPENDENCE WITH INTOXICATION UNSPECIFIED OTHER STIMULANT DEPENDENCE WITH WITHDRAWAL OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED MOOD OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC WITH DELUSIONS OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC UNSPECIFIED OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED ANXIETY OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SEXUAL DYSFUNCTION OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SLEEP OTHER STIMULANT DEPENDENCE WITH OTHER STIMULANT-INDUCED September 2, 2015 Copyright Health Information Designs, LLC 16

17 F1529 F1610 F16120 F16121 F16122 F16129 F1614 F16150 F16151 F16159 F16180 F16183 F16188 F1619 F1620 F16220 F16221 F16229 F1624 F16250 F16251 F16259 F16280 F16283 F16288 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses OTHER STIMULANT DEPENDENCE WITH UNSPECIFIED STIMULANT- INDUCED HALLUCINOGEN ABUSE UNCOMPLICATED HALLUCINOGEN ABUSE WITH INTOXICATION UNCOMPLICATED HALLUCINOGEN ABUSE WITH INTOXICATION WITH DELIRIUM HALLUCINOGEN ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE HALLUCINOGEN ABUSE WITH INTOXICATION UNSPECIFIED HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED MOOD HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH DELUSIONS HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH HALLUCINATIONS HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED PSYCHOTIC UNSPECIFIED HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED ANXIETY HALLUCINOGEN ABUSE WITH HALLUCINOGEN PERSISTING PERCEPTION (FLASHBACKS) HALLUCINOGEN ABUSE WITH OTHER HALLUCINOGEN-INDUCED HALLUCINOGEN ABUSE WITH UNSPECIFIED HALLUCINOGEN- INDUCED HALLUCINOGEN DEPENDENCE UNCOMPLICATED HALLUCINOGEN DEPENDENCE WITH INTOXICATION UNCOMPLICATED HALLUCINOGEN DEPENDENCE WITH INTOXICATION WITH DELIRIUM HALLUCINOGEN DEPENDENCE WITH INTOXICATION UNSPECIFIED HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED MOOD HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH DELUSIONS HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH HALLUCINATIONS HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC UNSPECIFIED HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED ANXIETY HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN PERSISTING PERCEPTION (FLASHBACKS) HALLUCINOGEN DEPENDENCE WITH OTHER HALLUCINOGEN- INDUCED September 2, 2015 Copyright Health Information Designs, LLC 17

18 F1629 F1810 F18120 F18121 F18129 F1814 F18150 F18151 F18159 F1817 F18180 F18188 F1819 F1820 F18220 F18221 F18229 F1824 F18250 F18251 F18259 F1827 F18280 F18288 F1829 F1910 F19120 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses HALLUCINOGEN DEPENDENCE WITH UNSPECIFIED HALLUCINOGEN- INDUCED INHALANT ABUSE UNCOMPLICATED INHALANT ABUSE WITH INTOXICATION UNCOMPLICATED INHALANT ABUSE WITH INTOXICATION DELIRIUM INHALANT ABUSE WITH INTOXICATION UNSPECIFIED INHALANT ABUSE WITH INHALANT-INDUCED MOOD INHALANT ABUSE WITH INHALANT-INDUCED PSYCHOTIC WITH DELUSIONS INHALANT ABUSE WITH INHALANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS INHALANT ABUSE WITH INHALANT-INDUCED PSYCHOTIC UNSPECIFIED INHALANT ABUSE WITH INHALANT-INDUCED DEMENTIA INHALANT ABUSE WITH INHALANT-INDUCED ANXIETY INHALANT ABUSE WITH OTHER INHALANT-INDUCED INHALANT ABUSE WITH UNSPECIFIED INHALANT-INDUCED INHALANT DEPENDENCE, UNCOMPLICATED INHALANT DEPENDENCE WITH INTOXICATION UNCOMPLICATED INHALANT DEPENDENCE WITH INTOXICATION DELIRIUM INHALANT DEPENDENCE WITH INTOXICATION UNSPECIFIED INHALANT DEPENDENCE WITH INHALANT-INDUCED MOOD INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC WITH DELUSIONS INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC, UNSPECIFIED INHALANT DEPENDENCE WITH INHALANT-INDUCED DEMENTIA INHALANT DEPENDENCE WITH INHALANT-INDUCED ANXIETY INHALANT DEPENDENCE WITH OTHER INHALANT-INDUCED INHALANT DEPENDENCE WITH UNSPECIFIED INHALANT-INDUCED OTHER PSYCHOACTIVE SUBSTANCE ABUSE UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION UNCOMPLICATED September 2, 2015 Copyright Health Information Designs, LLC 18

19 F19121 F19122 F19129 F1914 F19150 F19151 F19159 F1916 F1917 F19180 F19181 F19182 F19188 F1919 F1920 F19220 F19221 F19222 F19229 F19230 F19231 F19232 F19239 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCES OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH DELUSIONS OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING AMNESTIC OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING DEMENTIA OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED ANXIETY OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SEXUAL DYSFUNCTION OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SLEEP OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH OTHER PSYCHOACTIVE SUBSTANCE-INDUCED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH UNSPECIFIED PSYCHOACTIVE SUBSTANCE-INDUCED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION, UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL UNSPECIFIED September 2, 2015 Copyright Health Information Designs, LLC 19

20 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses F1924 F19250 F19251 F19259 F1926 F1927 F19280 F19281 F19282 F19288 F1929 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH DELUSIONS OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING AMNESTIC OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING DEMENTIA OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED ANXIETY OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SEXUAL DYSFUNCTION OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SLEEP OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH OTHER PSYCHOACTIVE SUBSTANCE-INDUCED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH UNSPECIFIED PSYCHOACTIVE SUBSTANCE-INDUCED Step 3 (Texas DFPS maximum recommended dose) TX DFPS Recommended Dosage Active Ingredient DEXMETHYLPHENIDATE DEXTROAMPHETAMINE METHAMPHETAMINE METHYLPHENIDATE Maximum Daily Dose 60 MG/DAY 50 MG/DAY 60 MG/DAY 25 MG/DAY 100 MG/DAY September 2, 2015 Copyright Health Information Designs, LLC 20

21 Label Name Step 4 (paid claim for another IR stimulant) Look back timeframe: 14 days IR Stimulants GCN ADDERALL 5MG TABLET ADDERALL 7.5MG TABLET ADDERALL 10MG TABLET ADDERALL 12.5MG TABLET ADDERALL 15MG TABLET ADDERALL 20MG TABLET ADDERALL 30MG TABLET MG TABLET MG TABLET MG TABLET MG TABLET MG TABLET MG TABLET MG TABLET DESOXYN 5MG TABLET DEXMETHYLPHENIDATE 2.5MG TABLET DEXMETHYLPHENIDATE 5MG TABLET DEXMETHYLPHENIDATE 10MG TABLET DEXTROAMPHETAMINE 5MG TABLET DEXTROAMPHETAMINE 10MG TABLET DEXTROAMPHETAMINE 5MG/5ML EVEKEO 5MG TABLET EVEKEO 10MG TABLET FOCALIN 2.5MG TABLET FOCALIN 5MG TABLET FOCALIN 10MG TABLET METHAMPHETAMINE 5MG TABLET METHYLIN 2.5MG CHEWABLE TABLET METHYLIN 5MG CHEWABLE TABLET METHYLIN 10MG CHEWABLE TABLET METHYLIN 5MG/5ML SOLUTION METHYLIN 10MG/5ML SOLUTION September 2, 2015 Copyright Health Information Designs, LLC 21

22 Step 4 (paid claim for another IR stimulant) Look back timeframe: 14 days IR Stimulants Label Name GCN METHYLPHENIDATE 5MG/5ML SOLUTION METHYLPHENIDATE 10MG/ML METHYLPHENIDATE 5MG TABLET METHYLPHENIDATE 10MG TABLET METHYLPHENIDATE 20MG TABLET PROCENTRA 5MG/5ML SOLUTION RITALIN 5MG TABLET RITALIN 10MG TABLET RITALIN 20MG TABLET ZENZEDI 2.5MG TABLET ZENZEDI 5MG TABLET ZENZEDI 7.5MG TABLET ZENZEDI 10MG TABLET ZENZEDI 15MG TABLET ZENZEDI 20MG TABLET ZENZEDI 30MG TABLET Step 6 (amphetamine salts immediate release tablets, dextroamphetamine immediate release tablets, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi) Label Name GCN ADDERALL 5MG TABLET ADDERALL 7.5MG TABLET ADDERALL 10MG TABLET ADDERALL 12.5MG TABLET ADDERALL 20MG TABLET ADDERALL 30MG TABLET MG TABLET MG TABLET MG TABLET MG TABLET MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 22

23 Step 6 (amphetamine salts immediate release tablets, dextroamphetamine immediate release tablets, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi) Label Name GCN 30MG TABLET DEXTROAMPHETAMINE 5MG TABLET DEXTROAMPHETAMINE 10MG TABLET DEXMETHYLPHENIDATE 2.5MG TABLET DEXMETHYLPHENIDATE 5MG TABLET DEXMETHYLPHENIDATE 10MG TABLET EVEKEO 5MG TABLET EVEKEO 10MG TABLET FOCALIN 2.5MG TABLET FOCALIN 5MG TABLET FOCALIN 10MG TABLET METHYLIN 2.5MG CHEWABLE TABLET METHYLIN 5MG CHEWABLE TABLET METHYLIN 10MG CHEWABLE TABLET METHYLIN 5MG/5ML SOLUTION METHYLIN 10MG/5ML SOLUTION METHYLPHENIDATE 5MG/5ML SOLUTION METHYLPHENIDATE 10MG/ML METHYLPHENIDATE 5MG TABLET METHYLPHENIDATE 10MG TABLET METHYLPHENIDATE 20MG TABLET PROCENTRA 5MG/5ML SOLUTION RITALIN 5MG TABLET RITALIN 10MG TABLET RITALIN 20MG TABLET ZENZEDI 2.5MG TABLET ZENZEDI 5MG TABLET ZENZEDI 7.5MG TABLET ZENZEDI 10MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 23

24 ICD-9 Code Description Step 8 (diagnosis of ADD or ADHD) Look back timeframe: 730 days ADD/ADHD Diagnoses ATTENTION DEFICIT WITHOUT MENTION OF HYPERACTIVITY ATTENTION DEFICIT WITH HYPERACTIVITY ICD-10 Code F900 F901 F902 F908 F909 Description ATTENTION-DEFICIT HYPERACTIVITY, PREDOMINANTLY INATTENTIVE TYPE ATTENTION-DEFICIT HYPERACTIVITY, PREDOMINANTLY HYPERACTIVE TYPE ATTENTION-DEFICIT HYPERACTIVITY, COMBINED TYPE ATTENTION-DEFICIT HYPERACTIVITY, OTHER TYPE ATTENTION-DEFICIT HYPERACTIVITY, UNSPECIFIED TYPE ICD-9 Code Description Step 9 (diagnosis of narcolepsy) Required diagnosis: 1 Look back timeframe: 730 days Narcolepsy Diagnoses NARCOLEPSY WITHOUT CATAPLEXY NARCOLEPSY WITH CATAPLEXY ICD-10 Code G47419 G47411 G47429 G47421 NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH CATAPLEXY Description NARCOLEPSY WITHOUT CATAPLEXY NARCOLEPSY WITH CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH CATAPLEXY September 2, 2015 Copyright Health Information Designs, LLC 24

25 Step 10 (dexmethylphenidate immediate release or methamphetamine) Dexmethylphenidate Immediate Release Drugs/Methamphetamines Label Name GCN DEXMETHYLPHENIDATE 2.5MG TABLET DEXMETHYLPHENIDATE 5MG TABLET DEXMETHYLPHENIDATE 10MG TABLET FOCALIN 2.5MG TABLET FOCALIN 5MG TABLET FOCALIN 10MG TABLET METHAMPHETAMINE 5MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 25

26 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Drugs Requiring Prior Authorization Label Name Drugs Requiring Prior Authorization GCN ADDERALL XR 5MG CAPSULE ADDERALL XR 10MG CAPSULE ADDERALL XR 15MG CAPSULE ADDERALL XR 20MG CAPSULE ADDERALL XR 25MG CAPSULE ADDERALL XR 30MG CAPSULE MG EXTENDED- 10MG EXTENDED- 15MG EXTENDED- 20MG EXTENDED- 25MG EXTENDED- 30MG EXTENDED CONCERTA ER 18MG TABLET CONCERTA ER 27MG TABLET CONCERTA ER 36MG TABLET CONCERTA ER 54MG TABLET DAYTRANA 10MG/9HR PATCH DAYTRANA 15MG/9HR PATCH DAYTRANA 20MG/9HR PATCH DAYTRANA 30MG/9HR PATCH DEXEDRINE SPANSULE 5MG DEXEDRINE SPANSULE 10MG DEXEDRINE SPANSULE 15MG DEXMETHYLPHENIDATE 15MG EXTENDED DEXMETHYLPHENIDATE 30MG EXTENDED September 2, 2015 Copyright Health Information Designs, LLC 26

27 Label Name DEXMETHYLPHENIDATE 40MG EXTENDED DEXTROAMPHETAMINE 5MG EXTENDED- DEXTROAMPHETAMINE 10MG EXTENDED- DEXTROAMPHETAMINE 15MG EXTENDED- Drugs Requiring Prior Authorization GCN FOCALIN XR 5MG CAPSULE FOCALIN XR 10MG CAPSULE FOCALIN XR 15MG CAPSULE FOCALIN XR 20MG CAPSULE FOCALIN XR 25MG CAPSULE FOCALIN XR 30MG CAPSULE FOCALIN XR 35MG CAPSULE FOCALIN XR 40MG CAPSULE METADATE CD 10MG CAPSULE METADATE CD 20MG CAPSULE METADATE CD 30MG CAPSULE METADATE CD 40MG CAPSULE METADATE CD 50MG CAPSULE METADATE CD 60MG CAPSULE METADATE ER 10MG TABLET SA METADATE ER 20MG TABLET ER METHYLPHENIDATE 20MG EXTENDED- METHYLPHENIDATE 30MG EXTENDED- METHYLPHENIDATE 40MG EXTENDED- METHYLPHENIDATE CD 10MG EXTENDED- METHYLPHENIDATE CD 20MG EXTENDED- METHYLPHENIDATE CD 30MG EXTENDED- METHYLPHENIDATE CD 40MG EXTENDED- METHYLPHENIDATE CD 50MG EXTENDED- METHYLPHENIDATE CD 60MG EXTENDED- METHYLPHENIDATE 18MG EXTENDED- RELEASE TABLET September 2, 2015 Copyright Health Information Designs, LLC 27

28 Label Name METHYLPHENDIATE 20MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 27MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 36MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 54MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 20MG SUSTAINED- RELEASE TABLET Drugs Requiring Prior Authorization GCN QUILLIVANT XR 25MG/5ML SUSP RITALIN LA 10MG CAPSULE RITALIN LA 20MG CAPSULE RITALIN LA 30MG CAPSULE RITALIN LA 40MG CAPSULE RITALIN SR 20MG TABLET VYVANSE 10MG CAPSULE VYVANSE 20MG CAPSULE VYVANSE 30MG CAPSULE VYVANSE 40MG CAPSULE VYVANSE 50MG CAPSULE VYVANSE 60MG CAPSULE VYVANSE 70MG CAPSULE September 2, 2015 Copyright Health Information Designs, LLC 28

29 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Clinical Edit Criteria Logic 1. Is the client less than (<) 6 years of age? [ ] Yes Deny [ ] No Go to #2 2. Does the client have a history of substance abuse in the last 365 days? [ ] Yes Deny [ ] No Go to #3 3. Is the request for greater than (>) the Texas Department of Family and Protective Services (DFPS) maximum recommended dose? [] Yes Deny [] No Go to #4 4. Does the client have a paid claim for another ER stimulant in the past 14 days? [ ] Yes Deny [ ] No Go to #5 5. Is the client greater than or equal to ( ) 19 years of age? [ ] Yes Go to #6 [ ] No Approve (365 days) 6. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [ ] Yes Approve (365 days) [ ] No Go to #7 7. Does the client have a diagnosis of narcolepsy in the last 730 days? [ ] Yes Go to #8 [ ] No Deny 8. Is the request for methylphenidate extended release tablets, methylphenidate sustained release tablets, or dextroamphetamine extended release capsules? [ ] Yes Approve (365 days) [ ] No Deny September 2, 2015 Copyright Health Information Designs, LLC 29

30 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Clinical Edit Criteria Logic Diagram The ER Formulations Clinical Edit Criteria Logic Diagram is shown on the following page. September 2, 2015 Copyright Health Information Designs, LLC 30

31 No No No Yes Yes Yes Yes No Texas Prior Authorization Program Clinical Edits Step 1 Step 2 Step 3 Step 4 Is the client less than 6 years of age? Does the client have a history of substance abuse in the last 365 days? Is the request for greater than the TX DFPS maximum recommended dose? Does the client have a paid claim for another ER stimulant in the past 14 days? Deny Step 5 Deny Deny Deny Is the client greater than Approve or equal to 19 years of (365 days) age? Step 6 Does the client have a diagnosis of ADD/ADHD in the last 730 days? Approve (365 days) Step 8 Step 7 Approve (365 days) Yes Is the request for methylphenidate ER, methylphenidate SR, or dextroamphetamine ER? Yes Does the client have a diagnosis of narcolepsy in the last 730 days? Deny Deny September 2, 2015 Copyright Health Information Designs, LLC 31

32 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Clinical Edit Criteria Supporting Tables Step 2 (history of substance abuse) Look back timeframe: 365 days For the list of diagnosis codes that pertain to this step, see the History of Substance Abuse Diagnoses table in the previous Supporting Tables section. Step 4 (paid claim for another ER stimulant) Look back timeframe: 14 days ER Stimulants Label Name GCN ADDERALL XR 5MG CAPSULE ADDERALL XR 10MG CAPSULE ADDERALL XR 15MG CAPSULE ADDERALL XR 20MG CAPSULE ADDERALL XR 25MG CAPSULE ADDERALL XR 30MG CAPSULE MG EXTENDED MG EXTENDED MG EXTENDED MG EXTENDED MG EXTENDED MG EXTENDED CONCERTA ER 18MG TABLET CONCERTA ER 27MG TABLET CONCERTA ER 36MG TABLET CONCERTA ER 54MG TABLET DAYTRANA 10MG/9HR PATCH DAYTRANA 15MG/9HR PATCH DAYTRANA 20MG/9HR PATCH September 2, 2015 Copyright Health Information Designs, LLC 32

33 Label Name Step 4 (paid claim for another ER stimulant) Look back timeframe: 14 days ER Stimulants GCN DAYTRANA 30MG/9HR PATCH DEXEDRINE SPANSULE 5MG DEXEDRINE SPANSULE 10MG DEXEDRINE SPANSULE 15MG DEXTROAMPHETAMINE 5MG EXTENDED DEXTROAMPHETAMINE 10MG EXTENDED DEXTROAMPHETAMINE 15MG EXTENDED FOCALIN XR 5MG CAPSULE FOCALIN XR 10MG CAPSULE FOCALIN XR 15MG CAPSULE FOCALIN XR 20MG CAPSULE FOCALIN XR 25MG CAPSULE FOCALIN XR 30MG CAPSULE FOCALIN XR 35MG CAPSULE FOCALIN XR 40MG CAPSULE METADATE CD 10MG CAPSULE METADATE CD 20MG CAPSULE METADATE CD 30MG CAPSULE METADATE CD 40MG CAPSULE METADATE CD 50MG CAPSULE METADATE CD 60MG CAPSULE METADATE ER 10MG TABLET SA METADATE ER 20MG TABLET ER METHYLPHENIDATE 20MG EXTENDED METHYLPHENIDATE 30MG EXTENDED METHYLPHENIDATE 40MG EXTENDED METHYLPHENIDATE CD 10MG EXTENDED METHYLPHENIDATE CD 20MG EXTENDED METHYLPHENIDATE CD 30MG EXTENDED METHYLPHENIDATE CD 40MG EXTENDED September 2, 2015 Copyright Health Information Designs, LLC 33

34 Label Name Step 4 (paid claim for another ER stimulant) Look back timeframe: 14 days ER Stimulants GCN METHYLPHENIDATE CD 50MG EXTENDED METHYLPHENIDATE CD 60MG EXTENDED METHYLPHENIDATE 18MG EXTENDED- RELEASE TABLET METHYLPHENDIATE 20MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 27MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 36MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 54MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 20MG SUSTAINED- RELEASE TABLET QUILLIVANT XR 25MG/5ML SUSP RITALIN LA 10MG CAPSULE RITALIN LA 20MG CAPSULE RITALIN LA 30MG CAPSULE RITALIN LA 40MG CAPSULE RITALIN SR 20MG TABLET VYVANSE 10MG CAPSULE VYVANSE 20MG CAPSULE VYVANSE 30MG CAPSULE VYVANSE 40MG CAPSULE VYVANSE 50MG CAPSULE VYVANSE 60MG CAPSULE VYVANSE 70MG CAPSULE Step 6 (diagnosis of ADD or ADHD) Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the ADD/ADHD Diagnoses table in the previous Supporting Tables section. September 2, 2015 Copyright Health Information Designs, LLC 34

35 Step 7 (diagnosis of narcolepsy) Required diagnosis: 1 Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the Narcolepsy Diagnoses table in the previous Supporting Tables section. Step 8 (methylphenidate extended release tablets, methylphenidate sustained release tablets, or dextroamphetamine extended release capsules) Label Name GCN DEXEDRINE SPANSULE 5MG DEXEDRINE SPANSULE 10MG DEXEDRINE SPANSULE 15MG DEXTROAMPHETAMINE 5MG EXTENDED- DEXTROAMPHETAMINE 10MG EXTENDED- DEXTROAMPHETAMINE 15MG EXTENDED METADATE ER 10MG TABLET SA METADATE ER 20MG TABLET ER METHYLPHENIDATE 10MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 20MG EXTENDED- RELEASE TABLET RITALIN SR 20MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 35

36 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN INTUNIV ER 1MG TABLET INTUNIV ER 2MG TABLET INTUNIV ER 3MG TABLET INTUNIV ER 4MG TABLET STRATTERA 10MG CAPSULE STRATTERA 18MG CAPSULE STRATTERA 25MG CAPSULE STRATTERA 40MG CAPSULE STRATTERA 60MG CAPSULE STRATTERA 80MG CAPSULE STRATTERA 100MG CAPSULE September 2, 2015 Copyright Health Information Designs, LLC 36

37 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Clinical Edit Criteria Logic 1. Is the client less than (<) 6 years of age? [ ] Yes Deny [ ] No Go to #2 2. Is the request for greater than (>) 2 units per day? [] Yes Deny [] No Go to #3 3. Is the client greater than or equal to ( ) 19 years of age? [ ] Yes Go to #4 [ ] No Approve (365 days) 4. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [ ] Yes Approve (365 days) [ ] No Deny September 2, 2015 Copyright Health Information Designs, LLC 37

38 Yes Yes Yes Yes Texas Prior Authorization Program Clinical Edits Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client less than 6 years of age? Is the request for greater than 2 units per day? Is the client greater than or equal to 19 years of age? Approve (365 days) Step 4 Deny Deny Does the client have a diagnosis of ADD/ADHD in the last 730 days? Deny Approve (365 days) September 2, 2015 Copyright Health Information Designs, LLC 38

39 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Clinical Edit Criteria Supporting Tables Step 4 (diagnosis of ADD or ADHD) Look back timeframe: 730 days For the list of diagnoses that pertain to this step, please see the ADD/ADHD Diagnoses table in a previous Supporting Tables section. September 2, 2015 Copyright Health Information Designs, LLC 39

40 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN CLONIDINE HCL ER MG DOSEPACK CLONIDINE HCL ER 0.1MG TABLET September 2, 2015 Copyright Health Information Designs, LLC 40

41 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Clinical Edit Criteria Logic 1. Is the client less than (<) 6 years of age? [ ] Yes Deny [ ] No - Go to #2 2. Is the request for greater than (>) 4 units per day? [ ] Yes Deny [ ] No Go to #3 3. Is the client greater than or equal to ( ) 19 years of age? [ ] Yes Go to #4 [ ] No Approve (1 day) 4. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [ ] Yes Approve (365 days) [ ] No Deny September 2, 2015 Copyright Health Information Designs, LLC 41

42 Yes Yes Yes Yes Texas Prior Authorization Program Clinical Edits Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client less than 6 years of age? Is the request for greater than 4 units per day? Is the client greater than or equal to 19 years of age? Approve (365 days) Deny Deny Step 4 Does the client have a diagnosis of ADD/ADHD in the last 730 days? Deny Approve (365 days) September 2, 2015 Copyright Health Information Designs, LLC 42

43 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Clinical Edit Criteria Supporting Tables Step 4 (diagnosis of ADD or ADHD) Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the ADD/ADHD Diagnoses table in a previous Supporting Tables section. September 2, 2015 Copyright Health Information Designs, LLC 43

44 Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clinical Edit Criteria References 1. Clinical Pharmacology [online database]. Tampa, FL: Gold Standard, Inc. October Available at Accessed on May 30, The American Academy of Pediatrics. Implementing the key action statements: An algorithm and explanation for process of care for the evaluation, diagnosis, treatment and monitoring of ADHD in children and adolescents. November 1, Available at 3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Emergency department visits involving attention deficit/hyperactivity disorder stimulant medications. Rockville, MD. January 24, Texas Department of Family and Protective Services and The University of Texas at Austin College of Pharmacy. Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care. September ICD-9-CM Diagnosis Codes Available at Accessed on April 3, ICD-10-CM Diagnosis Codes Available at Accessed on April 3, American Medical Association data files ICD-9-CM Diagnosis Codes. Available at 8. American Medical Association data files ICD-10-CM Diagnosis Codes. Available at September 2, 2015 Copyright Health Information Designs, LLC 44

45 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 07/15/2013 Initial publication 04/16/2014 Updated ER and NS written criteria 05/02/2014 Removed Clonidine ER from the non-stimulant edit and built a separate edit allowing for 4 units/day In the Clonidine ER section, amended Step 2 in the criteria logic to Is the request for greater than (>) 4 units per day? In the Clonidine ER section, amended Step 2 in the criteria logic diagram to Is the request for greater than (>) 4 units per day? 06/20/2014 Revised step 3 in the IR Formulations clinical edit criteria logic section from FDA maximum recommended dose to Texas Department of Family and Protective Services (DFPS) maximum recommended daily dose Revised step 3 in the IR Formulations clinical edit criteria logic diagram from FDA to TX DFPS In the IR Formulations section, added GCNs for dexmethylphenidate and methylphenidate to the supporting table for step 6 to reflect new age guidelines In the IR Formulations section, added the GCN for methamphetamine to the supporting table for step 11 Revised step 3 in the ER Formulations clinical edit criteria logic from FDA maximum recommended dose to Texas Department of Family and Protective Services (DFPS) maximum recommended daily dose Revised step 3 in the ER Formulations clinical edit criteria logic diagram from FDA to TX DFPS 02/27/2015 Revised approval duration for Step 8 in the clinical edit logic and diagram for IR formulations Revised approval duration for Step 6 in the clinical edit logic and diagram for ER formulations Revised approval duration for Step 4 in the clinical edit logic and diagram for Non-Stimulant Agents (including clonidine ER) September 2, 2015 Copyright Health Information Designs, LLC 45

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