Cytokine and CAM Antagonists

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1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Actemra (Tocilizumab) 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 te: Click the hyperlink to navigate directly to that section. Cimzia (Certolizumab pegol) 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 te: Click the hyperlink to navigate directly to that section. July 31, 2015 Copyright 2015 Health Information Designs, LLC 1

2 Kineret (Anakinra) 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 te: Click the hyperlink to navigate directly to that section. Ilaris (Canakinumab) 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 te: Click the hyperlink to navigate directly to that section. Orencia (Abatacept) 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 te: Click the hyperlink to navigate directly to that section. July 31, 2015 Copyright 2015 Health Information Designs, LLC 2

3 Simponi (Golimumab) 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 te: Click the hyperlink to navigate directly to that section. Stelara (Ustekinumab) 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 te: Click the hyperlink to navigate directly to that section. Xeljanz (Tofacitinib) 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 te: Click the hyperlink to navigate directly to that section. July 31, 2015 Copyright 2015 Health Information Designs, LLC 3

4 Revision tes Review of ICD-9 and ICD-10 codes July 31, 2015 Copyright 2015 Health Information Designs, LLC 4

5 Actemra (Tocilizumab) Drugs Requiring Prior Authorization Actemra Label Name GCN ACTEMRA 162MG/0.9ML SYRINGE July 31, 2015 Copyright 2015 Health Information Designs, LLC 5

6 Actemra (Tocilizumab) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? [] Go to #2 [] Go to #5 2. Is the client greater than or equal to ( ) 18 years of age? [] Go to #3 [] Deny 3. Does the client have 1 claim for a TNF blocker in the last 180 days? [] Go to #7 [] Go to #4 4. Does the client have a contraindication to or is the client non-responsive to a TNF-blocker? [manual] [] Go to #7 [] Deny 5. Does the client have a diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis in the last 730 days? [] Go to #6 [] Deny 6. Is the client 2 years of age? [] Go to #7 [] Deny 7. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Go to #8 8. Does the client have 1 claim for a TNF modifier in the last 14 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 6

7 Actemra (Tocilizumab) Clinical Edit Criteria Logic Diagram Step 1 Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? Step 5 Does the client have a diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis in the last 730 days? Step 6 Is the client 2 years of age? Step 2 Is the client 18 years of age? Step 3 Does the client have 1 claim for a TNF blocker in the last 180 days? Step 7 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis)? Step 4 Step 8 Does the client have a contraindication to or is the client nonresponsive to a TNFblocker? [manual] Does the client have 1 claim for a TNF modifier in the last 14 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 7

8 Actemra (Tocilizumab) Clinical Edit Criteria Supporting Tables ICD-9 Code Step 1 (diagnosis of rheumatoid arthritis) Description 7140 RHEUMATOID ARTHRITIS Look back timeframe: 730 days 7142 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT ICD-10 Code M0560 M05611 M05612 M05619 M05621 M05622 M05629 M05631 M05632 M05639 M05641 M05642 M05649 M05651 M05652 M05659 Description RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS July 31, 2015 Copyright 2015 Health Information Designs, LLC 8

9 M05661 M05662 M05669 M05671 M05672 M05679 M0569 M0570 M05711 M05712 M05719 M05721 M05722 M05729 M05731 M05732 M05739 M05741 M05742 M05749 M05751 M05752 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days RHEUMATOID ARTHRITIS OF RIGHT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF MULTIPLE SITES WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT July 31, 2015 Copyright 2015 Health Information Designs, LLC 9

10 M05759 M05761 M05762 M05769 M05771 M05772 M05779 M0579 M0580 M05811 M05812 M05819 M05821 M05822 M05829 M05831 M05832 M05839 M05841 M05842 M05849 M05851 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF MULTIPLE SITES WITHOUT ORGAN OR SYSTEMS INVOLVEMENT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HIP July 31, 2015 Copyright 2015 Health Information Designs, LLC 10

11 M05852 M05859 M05861 M05862 M05869 M05871 M05872 M05879 M0589 M059 M0600 M06011 M06012 M06019 M06021 M06022 M06029 M06031 M06032 M06039 M06041 M06042 M06049 M06051 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF MULTIPLE SITES RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR, UNSPECIFIED RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR UNSPECIFIED SITE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT HIP July 31, 2015 Copyright 2015 Health Information Designs, LLC 11

12 M06052 M06059 M06061 M06062 M06069 M06071 M06072 M06079 M0608 M0609 M061 M0680 M06811 M06812 M06819 M06821 M06822 M06829 M06831 M06832 M06839 M06841 M06842 M06849 M06851 M06852 M06859 M06861 M06862 M06869 M06871 M06872 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR VERTEBRAE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR MULTIPLE SITES ADULT-ONSET STILL'S DISEASE OTHER SPECIFIED RHEUMATOID ARTHRITIS UNSPECIFIED SITE OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT July 31, 2015 Copyright 2015 Health Information Designs, LLC 12

13 M06879 M0688 M0689 M069 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS VERTEBRAE OTHER SPECIFIED RHEUMATOID ARTHRITIS MULTIPLE SITES RHEUMATOID ARTHRITIS, UNSPECIFIED Step 3 (prior therapy with a TNF blocker) Look back timeframe: 180 days GCN Description CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML SYRINGE KIT ENBREL 25MG KIT ENBREL 25MG/0.5ML SYRINGE ENBREL 50MG/ML SURECLICK SYRINGE ENBREL 50MG/ML SYRINGE HUMIRA 20MG/0.4ML SYRINGE HUMIRA 40MG/0.8ML PEN HUMIRA 40MG/0.8ML SYRINGE HUMIRA STARTER PACK REMICADE 100MG VIAL SIMPONI 100MG/ML PEN INJECTOR SIMPONI 100MG/ML SYRINGE SIMPONI 50MG/0.5ML PEN INJECTOR SIMPONI 50MG/0.5ML SYRINGE SIMPONI ARIA 50MG/4ML VIAL Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) ICD-9 Code Description Look back timeframe: 730 days POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS, CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS, ACUTE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS July 31, 2015 Copyright 2015 Health Information Designs, LLC 13

14 Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days ICD-10 Code M0800 M08011 M08012 M08019 M08021 M08022 M08029 M08031 M08032 M08039 M08041 M08042 M08049 M08051 M08052 M08059 M08061 M08062 M08069 M08071 M08072 M08079 M0808 M0809 M0820 M08211 M08212 M08219 Description UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS VERTEBRAE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS MULTIPLE SITES JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET UNSPECIFIED SITE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT SHOULDER JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED SHOULDER July 31, 2015 Copyright 2015 Health Information Designs, LLC 14

15 M08221 M08222 M08229 M08231 M08232 M08239 M08241 M08242 M08249 M08251 M08252 M08259 M08261 M08262 M08269 M08271 M08272 M08279 M0828 M0829 M083 M0840 M08411 Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET VERTEBRAE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET MULTIPLE SITES JUVENILE RHEUMATOID POLYARTHRITIS (SERONEGATIVE) PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS UNSPECIFIED SITE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT SHOULDER July 31, 2015 Copyright 2015 Health Information Designs, LLC 15

16 M08412 M08419 M08421 M08422 M08429 M08431 M08432 M08439 M08441 M08442 M08449 M08451 M08452 M08459 M08461 M08462 M08469 M08471 M08472 M08479 M0848 Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS VERTEBRAE ICD-9 Code Description Step 7 (active infection) Look back timeframe: 180 days 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 July 31, 2015 Copyright 2015 Health Information Designs, LLC 16

17 Step 7 (active infection) Look back timeframe: 180 days 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 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 PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED PRIMARY TUBERCULOUS INFECTION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE PRIMARY TUBERCULOUS INFECTION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, UNSPECIFIED TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] July 31, 2015 Copyright 2015 Health Information Designs, LLC 17

18 Step 7 (active infection) Look back timeframe: 180 days OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, UNSPECIFIED OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, UNSPECIFIED PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF LUNG, INFILTRATIVE, UNSPECIFIED TUBERCULOSIS OF LUNG, INFILTRATIVE, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF LUNG, INFILTRATIVE, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE July 31, 2015 Copyright 2015 Health Information Designs, LLC 18

19 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI NOT FOUND BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF LUNG, NODULAR, UNSPECIFIED TUBERCULOSIS OF LUNG, NODULAR, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF LUNG, NODULAR, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF LUNG WITH CAVITATION, UNSPECIFIED TUBERCULOSIS OF LUNG WITH CAVITATION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF LUNG WITH CAVITATION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF BRONCHUS, UNSPECIFIED TUBERCULOSIS OF BRONCHUS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF BRONCHUS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) July 31, 2015 Copyright 2015 Health Information Designs, LLC 19

20 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND IN BACTERIAL CULTURE TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS FIBROSIS OF LUNG, UNSPECIFIED TUBERCULOUS FIBROSIS OF LUNG, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS FIBROSIS OF LUNG, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS BRONCHIECTASIS, UNSPECIFIED TUBERCULOUS BRONCHIECTASIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS BRONCHIECTASIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PNEUMONIA [ANY FORM], UNSPECIFIED TUBERCULOUS PNEUMONIA [ANY FORM], BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE July 31, 2015 Copyright 2015 Health Information Designs, LLC 20

21 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOUS PNEUMONIA [ANY FORM], BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PNEUMOTHORAX, UNSPECIFIED TUBERCULOUS PNEUMOTHORAX, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS PNEUMOTHORAX, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] OTHER SPECIFIED PULMONARY TUBERCULOSIS, UNSPECIFIED OTHER SPECIFIED PULMONARY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER SPECIFIED PULMONARY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] July 31, 2015 Copyright 2015 Health Information Designs, LLC 21

22 Step 7 (active infection) Look back timeframe: 180 days PULMONARY TUBERCULOSIS, UNSPECIFIED, UNSPECIFIED PULMONARY TUBERCULOSIS, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE PULMONARY TUBERCULOSIS, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PLEURISY, UNSPECIFIED TUBERCULOUS PLEURISY, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS PLEURISY, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PLEURISY, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PLEURISY, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PLEURISY, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PLEURISY, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, UNSPECIFIED TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY July 31, 2015 Copyright 2015 Health Information Designs, LLC 22

23 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, UNSPECIFIED ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS LARYNGITIS, UNSPECIFIED TUBERCULOUS LARYNGITIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS LARYNGITIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, UNSPECIFIED OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) July 31, 2015 Copyright 2015 Health Information Designs, LLC 23

24 Step 7 (active infection) Look back timeframe: 180 days OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] 4846 PNEUMONIA IN ASPERGILLOSIS 1363 PNEUMOCYSTOSIS ICD-10 Code B160 B161 B162 B169 B180 B181 B1910 B1911 A150 A154 A155 A156 A157 A158 A159 B440 B441 B447 B449 B59 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 CHRONIC VIRAL HEPATITIS B WITH DELTA-AGENT CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENT UNSPECIFIED VIRAL HEPATITIS B WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS B WITH HEPATIC COMA TUBERCULOSIS OF LUNG TUBERCULOSIS OF INTRATHORACIC LYMPH NODES TUBERCULOSIS OF LARYNX, TRACHEA AND BRONCHUS TUBERCULOUS PLEURISY PRIMARY RESPIRATORY TUBERCULOSIS OTHER RESPIRATORY TUBERCULOSIS RESPIRATORY TUBERCULOSIS UNSPECIFIED INVASIVE PULMONARY ASPERGILLOSIS OTHER PULMONARY ASPERGILLOSIS DISSEMINATED ASPERGILLOSIS ASPERGILLOSIS, UNSPECIFIED PNEUMOCYSTOSIS July 31, 2015 Copyright 2015 Health Information Designs, LLC 24

25 Step 8 (therapy with a TNF modifier) Look back timeframe: 14 days GCN Description ARZERRA 1000MG/50ML VIAL ARZERRA 100MG/5ML VIAL KINERET 100MG/0.67ML SYRINGE ORENCIA 125MG/ML SYRINGE ORENCIA 250MG VIAL RITUXAN 10MG/ML VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 25

26 Cimzia (Certolizumab pegol) Drugs Requiring Prior Authorization Cimzia Label Name GCN CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML STARTER KIT July 31, 2015 Copyright 2015 Health Information Designs, LLC 26

27 Cimzia (Certolizumab pegol) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis and/or rheumatoid arthritis in the last 730 days? [] Go to #2 [] Deny 2. Is the client greater than or equal to ( ) 18 years of age? [] Go to #3 [] Deny 3. Does the client have a history of a demyelinating disease (multiple sclerosis, optic neuritis, Guillain-Barre syndrome) in the last 365 days? [] Deny [] Go to #4 4. Does the client have a history of heart failure in the last 365 days? [] Deny [] Go to #5 5. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Go to #6 6. Does the client have a history of hematologic abnormalities in the last 60 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 27

28 Cimzia (Certolizumab pegol) Clinical Edit Criteria Logic Diagram Step 1 Does the client have a diagnosis of ankylosing spondylitis, Crohn s diseas, psoriatic arthritis and/ or rheumatoid arthritis in the last 730 days? Step 2 Is the client 18 years of age? Step 3 Does the client have a history of demyelinating disease in the last 365 days? Step 4 Does the client have a history of heart failure in the last 365 days? Step 5 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? Step 6 Does the client have a history of hematologic abnormalities in the last 60 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 28

29 Cimzia (Certolizumab pegol) Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) ICD-9 Code Description 7200 ANKYLOSING SPONDYLITIS Look back timeframe: 730 days 5550 REGIONAL ENTERITIS OF SMALL INTESTINE 5551 REGIONAL ENTERITIS OF LARGE INTESTINE 5552 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE 5559 REGIONAL ENTRITIS OF UNSPECIFIED SITE 6960 PSORIATIC ARTHROPATHY 7140 RHEUMATOID ARTHRITIS 7142 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT ICD-10 Code M450 M451 M452 M453 M454 M455 M456 M457 M458 M459 K5000 K50011 K50012 K50013 K50014 K50018 K50019 K5010 Description ANKYLOSING SPONDYLITIS OF MULTIPLE SITES IN SPINE ANKYLOSING SPONDYLITIS OF OCCIPITO-ATLANTO-AXIAL REGION ANKYLOSING SPONDYLITIS OF CERVICAL REGION ANKYLOSING SPONDYLITIS OF CERVICOTHORACIC REGION ANKYLOSING SPONDYLITIS OF THORACIC REGION ANKYLOSING SPONDYLITIS OF THORACOLUMBAR REGION ANKYLOSING SPONDYLITIS LUMBAR REGION ANKYLOSING SPONDYLITIS OF LUMBOSACRAL REGION ANKYLOSING SPONDYLITIS SACRAL AND SACROCOCCYGEAL REGION ANKYLOSING SPONDYLITIS OF UNSPECIFIED SITES IN SPINE CROHN'S DISEASE OF SMALL INTESTINE WITHOUT COMPLICATIONS CROHN'S DISEASE OF SMALL INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF SMALL INTESTINE WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE OF SMALL INTESTINE WITH FISTULA CROHN'S DISEASE OF SMALL INTESTINE WITH ABSCESS CROHN'S DISEASE OF SMALL INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF SMALL INTESTINE WITH UNSPECIFIED COMPLICATIONS CROHN'S DISEASE OF LARGE INTESTINE WITHOUT COMPLICATIONS July 31, 2015 Copyright 2015 Health Information Designs, LLC 29

30 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) K50111 K50112 K50113 K50114 K50118 K50119 K5080 K50811 K50812 K50813 K50814 K50818 K50819 K5090 K50911 K50912 K50913 K50914 K50918 K50919 L4050 L4051 L4052 L4054 L4059 M0560 M05611 M05612 Look back timeframe: 730 days CROHN'S DISEASE OF LARGE INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF LARGE INTESTINE WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE OF LARGE INTESTINE WITH FISTULA CROHN'S DISEASE OF LARGE INTESTINE WITH ABSCESS CROHN'S DISEASE OF LARGE INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF LARGE INTESTINE WITH UNSPECIFIED COMPLICATIONS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITHOUT COMPLICATIONS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH FISTULA CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH ABSCESS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH UNSPECIFIED COMPLICATIONS CROHN'S DISEASE, UNSPECIFIED WITHOUT COMPLICATIONS CROHN'S DISEASE, UNSPECIFIED, WITH RECTAL BLEEDING CROHN'S DISEASE, UNSPECIFIED, WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE, UNSPECIFIED, WITH FISTULA CROHN'S DISEASE, UNSPECIFIED, WITH ABSCESS CROHN'S DISEASE, UNSPECIFIED, WITH OTHER COMPLICATION CROHN'S DISEASE, UNSPECIFIED, WITH UNSPECIFIED COMPLICATIONS ARTHROPATHIC PSORIASIS UNSPECIFIED DISTAL INTERPHALANGEAL PSORIATIC ARTHROPATHY PSORIATIC ARTHRITIS MUTILANS PSORIATIC JUVENILE ARTHROPATHY OTHER PSORIATIC ARTHROPATHY RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS July 31, 2015 Copyright 2015 Health Information Designs, LLC 30

31 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) M05619 M05621 M05622 M05629 M05631 M05632 M05639 M05641 M05642 M05649 M05651 M05652 M05659 M05661 M05662 M05669 M05671 M05672 M05679 M0569 M0570 M05711 Look back timeframe: 730 days RHEUMATOID ARTHRITIS OF UNSPECIFIED SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF MULTIPLE SITES WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT July 31, 2015 Copyright 2015 Health Information Designs, LLC 31

32 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) M05712 M05719 M05721 M05722 M05729 M05731 M05732 M05739 M05741 M05742 M05749 M05751 M05752 M05759 Look back timeframe: 730 days RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT M05761 M05762 M05769 M05771 M05772 M05779 M0579 RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF MULTIPLE SITES WITHOUT ORGAN OR SYSTEMS INVOLVEMENT July 31, 2015 Copyright 2015 Health Information Designs, LLC 32

33 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) M0580 M05811 M05812 M05819 M05821 M05822 M05829 M05831 M05832 M05839 M05841 M05842 M05849 M05851 M05852 M05859 M05861 M05862 M05869 M05871 M05872 M05879 Look back timeframe: 730 days OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ANKLE AND FOOT July 31, 2015 Copyright 2015 Health Information Designs, LLC 33

34 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) M0589 M059 M0600 M06011 M06012 M06019 M06021 M06022 M06029 M06031 M06032 M06039 M06041 M06042 M06049 M06051 M06052 M06059 M06061 M06062 M06069 M06071 M06072 M06079 Look back timeframe: 730 days OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF MULTIPLE SITES RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR, UNSPECIFIED RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR UNSPECIFIED SITE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED ANKLE AND FOOT July 31, 2015 Copyright 2015 Health Information Designs, LLC 34

35 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) M0608 M0609 M061 M0680 M06811 M06812 M06819 M06821 M06822 M06829 M06831 M06832 M06839 M06841 M06842 M06849 M06851 M06852 M06859 M06861 M06862 M06869 M06871 M06872 M06879 M0688 M0689 M069 Look back timeframe: 730 days RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR VERTEBRAE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR MULTIPLE SITES ADULT-ONSET STILL'S DISEASE OTHER SPECIFIED RHEUMATOID ARTHRITIS UNSPECIFIED SITE OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS VERTEBRAE OTHER SPECIFIED RHEUMATOID ARTHRITIS MULTIPLE SITES RHEUMATOID ARTHRITIS, UNSPECIFIED Step 3 (history of demyelinating disease) Look back timeframe: 365 days ICD-9 Code Description 340 MULTIPLE SCLEROSIS July 31, 2015 Copyright 2015 Health Information Designs, LLC 35

36 Step 3 (history of demyelinating disease) Look back timeframe: 365 days OPTIC NEURITIS, UNSPECIFIED OPTIC PAPILLITIS RETROBULBAR NEURITIS (ACUTE) NUTRITIONAL OPTIC NEUROPATHY TOXIC OPTIC NEUROPATHY OTHER OPTIC NEURITIS 3570 GUILLAIN-BARRE SYNDROME ICD-10 Code Description G35 MULTIPLE SCLEROSIS H4600 OPTIC PAPILLITIS UNSPECIFIED EYE H4601 OPTIC PAPILLITIS RIGHT EYE H4602 OPTIC PAPILLITIS LEFT EYE H4603 OPTIC PAPILLITIS BILATERAL H4610 RETROBULBAR NEURITIS UNSPECIFIED EYE H4611 RETROBULBAR NEURITIS RIGHT EYE H4612 RETROBULBAR NEURITIS LEFT EYE H4613 RETROBULBAR NEURITIS BILATERAL H462 NUTRITIONAL OPTIC NEUROPATHY H463 TOXIC OPTIC NEUROPATHY H468 OTHER OPTIC NEURITIS H469 UNSPECIFIED OPTIC NEURITIS G610 GUILLAIN-BARRE SYNDROME Step 4 (history of heart failure) Look back timeframe: 365 days ICD-9 Code Description 4280 LEFT HEART FAILURE 4281 LEFT HEART FAILURE SYSTOLIC HEART FAILURE, UNSPECIFIED ACUTE SYSTOLIC HEART FAILURE CHRONIC SYSTOLIC HEART FAILURE ACUTE ON CHRONIC SYSTOLIC HEART FAILURE DIASTOLIC HEART FAILURE, UNSPECIFIED ACUTE DIASTOLIC HEART FAILURE CHRONIC DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE July 31, 2015 Copyright 2015 Health Information Designs, LLC 36

37 Step 4 (history of heart failure) Look back timeframe: 365 days COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE, UNSPECIFIED ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 4289 HEART FAILURE, UNSPECIFIED ICD-10 Code I2583 I2584 I2589 I259 I501 I5020 I5021 I5022 I5023 I5030 I5031 I5032 I5033 I5040 I5041 I5042 I5043 I509 Description CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE CHRONIC ISCHEMIC HEART DISEASE, UNSPECIFIED LEFT VENTRICULAR FAILURE UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE ACUTE SYSTOLIC (CONGESTIVE) HEART FAILURE CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE DIASTOLIC (CONGESTIVE) HEART FAILURE CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE HEART FAILURE, UNSPECIFIED Step 5 (active infection) Look back timeframe: 180 days For the list of active infection diagnosis codes that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. July 31, 2015 Copyright 2015 Health Information Designs, LLC 37

38 ICD-9 Code Step 6 (history of hematologic abnormalities) Description Look back timeframe: 60 days CONSTITUTIONAL RED BLOOD CELL APLASIA OTHER CONSTITUTIONAL APLASTIC ANEMIA ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA OTHER DRUG-INDUCED PANCYTOPENIA OTHER PANCYTOPENIA RED CELL APLASIA (ACQUIRED)(ADULT)(WITH THYMOMA) OTHER SPECIFIED APLASTIC ANEMIAS 2849 APLASTIC ANEMIA, UNSPECIFIED NEUTROPENIA, UNSPECIFIED CONGENITAL NEUTROPENIA CYCLIC NEUTROPENIA DRUG INDUCED NEUTROPENIA NEUTROPENIA DUE TO INFECTION OTHER NEUTROPENIA LEUKOCYTOPENIA, UNSPECIFIED LYMPHOCYTOPENIA OTHER DECREASED WHITE BLOOD CELL COUNT PRIMARY THROMBOCYTOPENIA,UNSPECIFIED IMMUNE THROMBOCYTOPENIC PURPURA EVANS' SYNDROME CONGENITAL AND HEREDITARY THROMBOCYTOPENIC PURPURA OTHER PRIMARY THROMBOCYTOPENIA POSTTRANSFUSION PURPURA OTHER SECONDARY THROMBOCYTOPENIA 2875 THROMBOCYTOPENIA, UNSPECIFIED ICD-10 Code D6101 D6109 D611 D612 D613 D61810 D61811 D61818 D6189 Description APLASTIC ANEMIA, UNSPECIFIED OTHER CONSTITUTIONAL APLASTIC ANEMIA DRUG-INDUCED APLASTIC ANEMIA APLASTIC ANEMIA DUE TO OTHER EXTERNAL AGENTS IDIOPATHIC APLASTIC ANEMIA ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA OTHER DRUG-INDUCED PANCYTOPENIA OTHER PANCYTOPENIA OTHER SPECIFIED APLASTIC ANEMIAS AND OTHER BONE MARROW FAILURE SYNDROMES July 31, 2015 Copyright 2015 Health Information Designs, LLC 38

39 D619 D693 D6941 D6942 D6949 D6951 D6959 D696 D700 D701 D702 D703 D704 D708 D709 D72810 D72818 D72819 Step 6 (history of hematologic abnormalities) Look back timeframe: 60 days APLASTIC ANEMIA, UNSPECIFIED IMMUNE THROMBOCYTOPENIC PURPURA EVANS SYNDROME CONGENITAL AND HEREDITARY THROMBOCYTOPENIA PURPURA OTHER PRIMARY THROMBOCYTOPENIA POSTTRANSFUSION PURPURA OTHER SECONDARY THROMBOCYTOPENIA THROMBOCYTOPENIA, UNSPECIFIED CONGENITAL AGRANULOCYTOSIS AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY OTHER DRUG-INDUCED AGRANULOCYTOSIS NEUTROPENIA DUE TO INFECTION CYCLIC NEUTROPENIA OTHER NEUTROPENIA NEUTROPENIA, UNSPECIFIED LYMPHOCYTOPENIA OTHER DECREASED WHITE BLOOD CELL COUNT DECREASED WHITE BLOOD CELL COUNT UNSPECIFIED July 31, 2015 Copyright 2015 Health Information Designs, LLC 39

40 Kineret (Anakinra) Drugs Requiring Prior Authorization Kineret Label Name GCN KINERET 100MG/0.67ML SYRINGE July 31, 2015 Copyright 2015 Health Information Designs, LLC 40

41 Kineret (Anakinra) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? [] Go to #2 [] Go to #5 2. Is the client greater than or equal to ( ) 18 years of age? [] Go to #3 [] Deny 3. Does the client have 1 claim for a disease modifying antirheumatic drug (DMARD) in the last 180 days? [] Go to #6 [] Go to #4 4. Does the client have a contraindication to or is the client non-responsive to DMARDs? [manual] [] Go to #6 [] Deny 5. Does the client have a diagnosis of cryopyrin-associated periodic syndrome (CAPS) in the last 730 days? [] - Go to #6 [] - Deny 6. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Go to #7 7. Does the client have 1 claim for a TNF blocker in the last 14 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 41

42 Kineret (Anakinra) Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Step 4 Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? Is the client 18 years of age? Does the client have 1 claim for a DMARD in the last 180 days? Does the client have a contraindication to or is the client nonresponsive to DMARDs? [manual] Step 5 Does the client have a diagnosis of cryopyrinassociated periodic syndrome in the last 730 days? Step 6 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? Step 7 Does the client have 1 claim for a TNF blocker in the last 14 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 42

43 Kineret (Anakinra) Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days For the list of rheumatoid arthritis diagnosis codes that pertain to this step, see the Rheumatoid Arthritis Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 3 (history of DMARD) Look back timeframe: 180 days Label Name GCN AZASAN 75 MG TABLET AZASAN 100 MG TABLET AZATHIOPRINE 50 MG TABLET CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE MODIFIED 25 MG CYCLOSPORINE 50 MG CAPSULE CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE MODIFIED 100 MG CYCLOSPORINE 100 MG/ML CYCLOSPORINE 100 MG/ML HYDROXYCHLOROQUINE 200 MG TABLET LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE 20 MG TABLET METHOTREXATE 2.5 MG TABLET METHOTREXATE 2.5 MG TABLET SULFASALAZINE 500 MG TABLET SULFASALAZINE DR 500 MG TABLET July 31, 2015 Copyright 2015 Health Information Designs, LLC 43

44 Step 5 (diagnosis of cryopyrin-associated periodic syndrome) Look back timeframe: 730 days ICD-9 Code Description OTHER SPECIFIED CONGENITAL ANOMALIES ICD-10 Code Description Q898 OTHER SPECIFIED CONGENITAL MALFORMATIONS Step 6 (active infection) Look back timeframe: 180 days For the list of active infection diagnoses that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 7 (prior therapy with a TNF blocker) Look back timeframe: 14 days GCN Description CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML SYRINGE KIT ENBREL 25MG KIT ENBREL 25MG/0.5ML SYRINGE ENBREL 50MG/ML SURECLICK SYRINGE ENBREL 50MG/ML SYRINGE HUMIRA 20MG/0.4ML SYRINGE HUMIRA 40MG/0.8ML PEN HUMIRA 40MG/0.8ML SYRINGE HUMIRA STARTER PACK REMICADE 100MG VIAL SIMPONI 100MG/ML PEN INJECTOR SIMPONI 100MG/ML SYRINGE SIMPONI 50MG/0.5ML PEN INJECTOR SIMPONI 50MG/0.5ML SYRINGE SIMPONI ARIA 50MG/4ML VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 44

45 Ilaris (Canakinumab) Drugs Requiring Prior Authorization Ilaris Label Name GCN ILARIS 180MG VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 45

46 Ilaris (Canakinumab) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of cryopyrin-associated periodic syndrome (CAPS) in the last 730 days? [] Go to #3 [] Go to #2 2. Does the client have a diagnosis of systemic juvenile idiopathic arthritis (SJIA) in the last 730 days? [] Go to #4 [] - Deny 3. Is the client greater than or equal to ( ) 4 years of age? [] Go to #5 [] Deny 4. Is the client greater than or equal to ( ) 2 years of age? [] Go to #5 [] - Deny 5. Does the client have 1 claim for an interleukin-1 (IL-1) inhibitor or a tumor necrosis factor (TNF) blocker in the last 14 days? [] Deny [] Go to #6 6. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 46

47 Ilaris (Canakinumab) Clinical Edit Criteria Logic Diagram Step 1 Step 3 Does the client have a diagnosis of CAPS in the last 730 days? Is the client 4 years of age? Step 2 Step 4 Step 5 Does the client have a diagnosis of SJIA in the last 730 days? Is the client 2 years of age? Does the client have 1 claim for an IL-1 inhibitor or TNFblocker in the last 14 days? Step 6 Does the client have an active infection in the last 180 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 47

48 Ilaris (Canakinumab) Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of cryopyrin-associated periodic syndrome) Look back timeframe: 730 days For the list of cryopyrin-associated periodic syndrome diagnosis codes that pertain to this step, see the Cryopyrin-Associated Periodic Syndrome Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. ICD-9 Code Step 2 (diagnosis of systemic juvenile idiopathic arthritis) Description Look back timeframe: 730 days POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS, CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS, ACUTE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS ICD-10 Code M0800 M08011 M08012 M08019 M08021 M08022 M08029 M08031 M08032 M08039 M08041 M08042 M08049 M08051 Description UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT HIP July 31, 2015 Copyright 2015 Health Information Designs, LLC 48

49 M08052 M08059 M08061 M08062 M08069 M08071 M08072 M08079 M0808 M0809 M0820 M08211 M08212 M08219 M08221 M08222 M08229 M08231 M08232 M08239 M08241 M08242 M08249 M08251 M08252 Step 2 (diagnosis of systemic juvenile idiopathic arthritis) Look back timeframe: 730 days UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS VERTEBRAE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS MULTIPLE SITES JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET UNSPECIFIED SITE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT SHOULDER JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED SHOULDER JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT HIP July 31, 2015 Copyright 2015 Health Information Designs, LLC 49

50 M08259 M08261 M08262 M08269 M08271 M08272 M08279 M0828 M0829 M083 M0840 M08411 M08412 M08419 M08421 M08422 M08429 M08431 M08432 M08439 M08441 M08442 M08449 M08451 M08452 M08459 M08461 Step 2 (diagnosis of systemic juvenile idiopathic arthritis) Look back timeframe: 730 days JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET VERTEBRAE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET MULTIPLE SITES JUVENILE RHEUMATOID POLYARTHRITIS (SERONEGATIVE) PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS UNSPECIFIED SITE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT KNEE July 31, 2015 Copyright 2015 Health Information Designs, LLC 50

51 M08462 M08469 M08471 M08472 M08479 M0848 Step 2 (diagnosis of systemic juvenile idiopathic arthritis) Look back timeframe: 730 days PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS VERTEBRAE Step 5 (prior therapy with a TNF blocker or IL-1 inhibitor) Look back timeframe: 14 days GCN Description CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML SYRINGE KIT ENBREL 25MG KIT ENBREL 25MG/0.5ML SYRINGE ENBREL 50MG/ML SURECLICK SYRINGE ENBREL 50MG/ML SYRINGE HUMIRA 20MG/0.4ML SYRINGE HUMIRA 40MG/0.8ML PEN HUMIRA 40MG/0.8ML SYRINGE HUMIRA STARTER PACK REMICADE 100MG VIAL SIMPONI 100MG/ML PEN INJECTOR SIMPONI 100MG/ML SYRINGE SIMPONI 50MG/0.5ML PEN INJECTOR SIMPONI 50MG/0.5ML SYRINGE SIMPONI ARIA 50MG/4ML VIAL ARCALYST 220MG INJECTION KINERET 100MG/0.67ML SYRINGE July 31, 2015 Copyright 2015 Health Information Designs, LLC 51

52 Step 6 (active infection) Look back timeframe: 180 days For the list of active infection diagnosis codes that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. July 31, 2015 Copyright 2015 Health Information Designs, LLC 52

53 Orencia (Abatacept) Drugs Requiring Prior Authorization Orencia Label Name GCN ORENCIA 125 MG/ML SYRINGE ORENCIA 250 MG VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 53

54 Orencia (Abatacept) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? [] Go to #2 [] Go to #3 2. Is the client greater than or equal to ( ) 18 years of age? [] Go to #5 [] Deny 3. Does the client have a diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis in the last 730 days? [] Go to #4 [] Deny 4. Is the client 6 years of age? [] Go to #5 [] Deny 5. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Go to #6 6. Does the client have 1 claim for a TNF blocker in the last 14 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 54

55 Orencia (Abatacept) Clinical Edit Criteria Logic Diagram Step 1 Step 2 Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? Is the client 18 years of age? Step 3 Step 5 Does the client have a diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis in the last 730 days? Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? Step 4 Step 6 Is the client 6 years of age? Does the client have 1 claim for a TNF blocker in the last 14 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 55

56 Orencia (Abatacept) Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days For the list of rheumatoid arthritis diagnosis codes that pertain to this step, see the Rheumatoid Arthritis Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 3 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days For the list of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis diagnosis codes that pertain to this step, see the Polyarticular Idiopathic Arthritis or Systemic Juvenile Idiopathic Arthritis Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 5 (active infection) Look back timeframe: 180 days For the list of active infection diagnosis codes that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 6 (prior therapy with a TNF blocker) Look back timeframe: 14 days GCN Description CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML SYRINGE KIT ENBREL 25MG KIT ENBREL 25MG/0.5ML SYRINGE July 31, 2015 Copyright 2015 Health Information Designs, LLC 56

57 Step 6 (prior therapy with a TNF blocker) Look back timeframe: 14 days GCN Description ENBREL 50MG/ML SURECLICK SYRINGE ENBREL 50MG/ML SYRINGE HUMIRA 20MG/0.4ML SYRINGE HUMIRA 40MG/0.8ML PEN HUMIRA 40MG/0.8ML SYRINGE HUMIRA STARTER PACK REMICADE 100MG VIAL SIMPONI 100MG/ML PEN INJECTOR SIMPONI 100MG/ML SYRINGE SIMPONI 50MG/0.5ML PEN INJECTOR SIMPONI 50MG/0.5ML SYRINGE SIMPONI ARIA 50MG/4ML VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 57

58 Simponi (Golimumab) Drugs Requiring Prior Authorization Simponi Label Name GCN SIMPONI 100 MG/ML PEN INJECTOR SIMPONI 100 MG/ML SYRINGE SIMPONI 50 MG/0.5 ML PEN INJECTOR SIMPONI 50MG/0.5 ML SYRINGE SIMPONI ARIA 50 MG/4 ML VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 58

59 Simponi (Golimumab) Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 18 years of age? [] Go to #2 [] Deny 2. Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? [] Go to #4 [] Go to #3 3. Does the client have a diagnosis of ankylosing spondylitis, psoriatic arthritis and/or ulcerative colitis in the last 730 days? [] Go to #5 [] Deny 4. Does the client have 1 claim for methotrexate in the last 60 days? [] Go to #5 [] Deny 5. Does the client have a history of heart failure in the last 365 days? [] Deny [] Go to #6 6. Does the client have a history of demyelinating disease (multiple sclerosis, optic neuritis and/or Guillain-Barre syndrome) in the last 365 days? [] Deny [] Go to #7 7. Does the client have a history of hematologic abnormalities in the last 180 days? [] Deny [] Go to #8 8. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] (Approve 365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 59

60 Simponi (Golimumab) Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 4 Is the client 18 years of age? Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? Does the client have 1 claim for methotrexate in the last 60 days? Step 3 Does the client have a diagnosis of ankylosing spondylitis, psoriatic arthritis and/ or ulcerative colitis in the last 730 days? Step 5 Does the client have a history of heart failure in the last 365 days? Step 6 Does the client have a history of demyelinating disease in the last 365 days? Step 7 Does the client have a history of hematologic abnormalities in the last 180 days? Step 8 Approve Request (365 days) Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? July 31, 2015 Copyright 2015 Health Information Designs, LLC 60

61 Simponi (Golimumab) Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days For the list of rheumatoid arthritis diagnoses codes that pertain to this step, see the Rheumatoid Arthritis Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 3 (diagnosis of ankylosing spondylitis, psoriatic arthritis, and/or ulcerative colitis) Look back timeframe: 730 days ICD-9 Code Description 7200 ANKYLOSING SPONDYLITIS 6960 PSORIATIC ARTHROPATHY 5560 ULCERATIVE (CHRONIC) ENTEROCOLITIS 5561 ULCERATIVE (CHRONIC) ILEOCOLITIS 5562 ULCERATIVE (CHRONIC) PROCTITIS 5563 ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS 5564 PSEUDOPOLYPOSIS OF COLON 5565 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS 5566 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS 5568 OTHER ULCERATIVE COLITIS 5569 ULCERATIVE COLITIS, UNSPECIFIED ICD-10 Code Description M450 ANKYLOSING SPONDYLITIS OF MULTIPLE SITES IN SPINE M451 ANKYLOSING SPONDYLITIS OF OCCIPITO-ATLANTO-AXIAL REGION M452 ANKYLOSING SPONDYLITIS OF CERVICAL REGION M453 ANKYLOSING SPONDYLITIS OF CERVICOTHORACIC REGION M454 ANKYLOSING SPONDYLITIS OF THORACIC REGION M455 ANKYLOSING SPONDYLITIS OF THORACOLUMBAR REGION M456 ANKYLOSING SPONDYLITIS LUMBAR REGION M457 ANKYLOSING SPONDYLITIS OF LUMBOSACRAL REGION July 31, 2015 Copyright 2015 Health Information Designs, LLC 61

62 M458 M459 L4050 L4051 L4052 L4059 K5100 K51011 K51012 K51013 K51014 K51018 K51019 K5120 K51211 K51212 K51213 K51214 K51218 K51219 K5130 K51311 K51312 K51313 K51314 K51318 K51319 K5140 K51411 K51412 K51413 K51414 Step 3 (diagnosis of ankylosing spondylitis, psoriatic arthritis, and/or ulcerative colitis) Look back timeframe: 730 days ANKYLOSING SPONDYLITIS SACRAL AND SACROCOCCYGEAL REGION ANKYLOSING SPONDYLITIS OF UNSPECIFIED SITES IN SPINE ARTHROPATHIC PSORIASIS UNSPECIFIED DISTAL INTERPHALANGEAL PSORIATIC ARTHROPATHY PSORIATIC ARTHRITIS MUTILANS OTHER PSORIATIC ARTHROPATHY ULCERATIVE (CHRONIC) PANCOLITIS WITHOUT COMPLICATIONS ULCERATIVE (CHRONIC) PANCOLITIS WITH RECTAL BLEEDING ULCERATIVE (CHRONIC) PANCOLITIS WITH INTESTINAL OBSTRUCTION ULCERATIVE (CHRONIC) PANCOLITIS WITH FISTULA ULCERATIVE (CHRONIC) PANCOLITIS WITH ABSCESS ULCERATIVE (CHRONIC) PANCOLITIS WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) PANCOLITIS WITH UNSPECIFIED COMPLICATIONS ULCERATIVE (CHRONIC) PROCTITIS WITHOUT COMPLICATIONS ULCERATIVE (CHRONIC) PROCTITIS WITH RECTAL BLEEDING ULCERATIVE (CHRONIC) PROCTITIS WITH INTESTINAL OBSTRUCTION ULCERATIVE (CHRONIC) PROCTITIS WITH FISTULA ULCERATIVE (CHRONIC) PROCTITIS WITH ABSCESS ULCERATIVE (CHRONIC) PROCTITIS WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) PROCTITIS WITH UNSPECIFIED COMPLICATIONS ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITHOUT COMPLICATIONS ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH RECTAL BLEEDING ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH INTESTINAL OBSTRUCTION ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH FISTULA ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH ABSCESS ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH UNSPECIFIED COMPLICATIONS INFLAMMATORY POLYPS OF COLON WITHOUT COMPLICATIONS INFLAMMATORY POLYPS OF COLON WITH RECTAL BLEEDING INFLAMMATORY POLYPS OF COLON WITH INTESTINAL OBSTRUCTION INFLAMMATORY POLYPS OF COLON WITH FISTULA INFLAMMATORY POLYPS OF COLON WITH ABSCESS July 31, 2015 Copyright 2015 Health Information Designs, LLC 62

63 K51418 K51419 K5150 K51511 K51512 K51513 K51514 K51518 K51519 K5180 K51811 K51812 K51813 K51814 K51818 K51819 K5190 K51911 K51912 K51913 K51914 K51918 K51919 Step 3 (diagnosis of ankylosing spondylitis, psoriatic arthritis, and/or ulcerative colitis) Look back timeframe: 730 days INFLAMMATORY POLYPS OF COLON WITH OTHER COMPLICATION INFLAMMATORY POLYPS OF COLON WITH UNSPECIFIED COMPLICATIONS LEFT SIDED COLITIS WITHOUT COMPLICATIONS LEFT SIDED COLITIS WITH RECTAL BLEEDING LEFT SIDED COLITIS WITH INTESTINAL OBSTRUCTION LEFT SIDED COLITIS WITH FISTULA LEFT SIDED COLITIS WITH ABSCESS LEFT SIDED COLITIS WITH OTHER COMPLICATION LEFT SIDED COLITIS WITH UNSPECIFIED COMPLICATIONS OTHER ULCERATIVE COLITIS WITHOUT COMPLICATIONS OTHER ULCERATIVE COLITIS WITH RECTAL BLEEDING OTHER ULCERATIVE COLITIS WITH INTESTINAL OBSTRUCTION OTHER ULCERATIVE COLITIS WITH FISTULA OTHER ULCERATIVE COLITIS WITH ABSCESS OTHER ULCERATIVE COLITIS WITH OTHER COMPLICATION OTHER ULCERATIVE COLITIS WITH UNSPECIFIED COMPLICATIONS ULCERATIVE COLITIS, UNSPECIFIED WITHOUT COMPLICATIONS ULCERATIVE COLITIS, UNSPECIFIED WITH RECTAL BLEEDING ULCERATIVE COLITIS, UNSPECIFIED WITH INTESTINAL OBSTRUCTION ULCERATIVE COLITIS, UNSPECIFIED WITH FISTULA ULCERATIVE COLITIS, UNSPECIFIED WITH ABSCESS ULCERATIVE COLITIS, UNSPECIFIED WITH OTHER COMPLICATION ULCERATIVE COLITIS, UNSPECIFIED WITH UNSPECIFIED COMPLICATIONS Step 4 (prior therapy with methotrexate) Look back timeframe: 60 days GCN Description METHOTREXATE 2.5 MG TABLET METHOTREXATE 2.5 MG TABLET July 31, 2015 Copyright 2015 Health Information Designs, LLC 63

64 Step 5 (history of heart failure) Look back timeframe: 365 days For the list of heart failure diagnosis codes that pertain to this step, see the Heart Failure Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 6 (history of demyelinating disease) Look back timeframe: 365 days For the list of demyelinating disease diagnosis codes that pertain to this step, see the Demyelinating Disease Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 7 (history of hematologic abnormalities) Look back timeframe: 60 days For the list of hematologic abnormalities diagnosis codes that pertain to this step, see the Hematologic Abnormalities Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 8 (active infection) Look back timeframe: 180 days For the list of active infection diagnosis codes that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. July 31, 2015 Copyright 2015 Health Information Designs, LLC 64

65 Stelara (Ustekinumab) Drugs Requiring Prior Authorization Stelara Label Name GCN STELARA 45 MG/0.5 ML SYRINGE STELARA 45 MG/0.5 ML VIAL STELARA 90 MG/ML SYRINGE July 31, 2015 Copyright 2015 Health Information Designs, LLC 65

66 Stelara (Ustekinumab) Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 18 years of age? [] Go to #2 [] Deny 2. Does the client have a diagnosis of plaque psoriasis and/or psoriatic arthritis in the last 730 days? [] Go to #3 [] Deny 3. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 66

67 Stelara (Ustekinumab) Clinical Edit Criteria Logic Diagram Step 1 Step 2 Is the client 18 years of age? Does the client have a diagnosis of plaque psoriasis and/or psoriatic arthritis in the last 730 days? Step 3 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 67

68 Stelara (Ustekinumab) Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of plaque psoriasis and/or psoriatic arthritis) Look back timeframe: 730 days ICD-9 Code Description 6960 PSORIATIC ARTHROPATHY 6961 OTHER PSORIASIS ICD-10 Code L400 L401 L402 L403 L404 L4059 L408 L409 Description PSORIASIS VULGARIS GENERALIZED PUSTULAR PSORIASIS ACRODERMATITIS CONTINUA PUSTULOSIS PALMARIS ET PLANTARIS GUTTATE PSORIASIS OTHER PSORIATIC ARTHROPATHY OTHER PSORIASIS PSORIASIS, UNSPECIFIED Step 3 (active infection) Look back timeframe: 180 days For the list of active infection diagnosis codes that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. July 31, 2015 Copyright 2015 Health Information Designs, LLC 68

69 Xeljanz (Tofacitinib) Drugs Requiring Prior Authorization Xeljanz Label Name GCN XELJANZ 5 MG TABLET July 31, 2015 Copyright 2015 Health Information Designs, LLC 69

70 Xeljanz (Tofacitinib) Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 18 years of age? [] Go to #2 [] Deny 2. Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? [] Go to #3 [] Deny 3. Does the client have 1 claim for methotrexate in the last 730 days? [] Go to #5 [] Go to #4 4. Does the client have a history of inadequate response or intolerance to methotrexate? [manual] [] Go to #5 [] Deny 5. Does the client have 1 claim for a biological DMARD or potent immunosuppressant in the last 60 days? [] Deny [] Go to #6 6. Does the client have 1 claim for a strong CYP3A4 inducer in the last 60 days? [] Deny [] Go to #7 7. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 70

71 Xeljanz (Tofacitinib) Clinical Edit Criteria Logic Diagram Step 1 Is the client 18 years of age? Step 2 Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? Step 3 Does the client have 1 claim for methotrexate in the last 730 days? Step 5 Does the client have 1 claim for a biological DMARD or potent immunosuppressant in the last 60 days? Step 4 Does the client have a history of inadequate response or intolerance to methotrexate? [manual] Step 6 Does the client have 1 claim for a strong CYP3A4 inducer in the last 60 days? Step 7 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 71

72 Xeljanz (Tofacitinib) Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days For the list of rheumatoid arthritis diagnosis codes that pertain to this step, see the Rheumatoid Arthritis Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. Step 3 (prior therapy with methotrexate) Look back timeframe: 730 days GCN Description METHOTREXATE 2.5 MG TABLET METHOTREXATE 2.5 MG TABLET Step 5 (prior therapy with a DMARD or potent immunosuppressant) Look back timeframe: 60 days GCN Description KINERET 100 MG/0.67 ML SYRINGE RITUXAN 10 MG/ML VIAL ARZERRA 1000 MG/50ML VIAL ARZERRA 100 MG/5ML VIAL ORENCIA 125 MG/ML SYRING ORENCIA 250 MG VIAL ACTEMRA 162 MG/0.9ML SYRINGE ACTEMRA 200 MG/10ML VIAL ACTEMRA 400 MG/20ML VIAL ACTEMRA 80 MG/4ML VIAL CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE MODIFIED 25 MG CYCLOSPORINE 50 MG CAPSULE CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE MODIFIED 100 MG July 31, 2015 Copyright 2015 Health Information Designs, LLC 72

73 Step 5 (prior therapy with a DMARD or potent immunosuppressant) Look back timeframe: 60 days GCN Description CYCLOSPORINE 100 MG/ML CYCLOSPORINE 100 MG/ML AZASAN 100 MG TABLET AZASAN 75 MG TABLET AZATHIOPRINE 50 MG TABLET TACROLIMUS 0.5 MG CAPSULE TACROLIMUS 1 MG CAPSULE TACROLIMUS 5 MG CAPSULE ASTAGRAF XL 0.5 MG CAPSULE ASTAGRAF XL 1 MG CAPSULE ASTAGRAF XL 5 MG CAPSULE MYCOPHENOLATE 250 MG CAPSULE MYCOPHENOLATE 500 MG TABLET CELLCEPT 200 MG/ML ORAL SUSP MYCOPHENOLIC ACID DR 180 MG TAB MYCOPHENOLIC ACID DR 360 MG TAB Step 6 (prior therapy with a strong CYP3A4 inducer) Look back timeframe: 60 days GCN Description PHENYTOIN 100 MG/4 ML SUSPENSION PHENYTOIN 100 MG/4 ML SUSPENSION PHENYTOIN 100 MG/4 ML SUSPENSION PHENYTOIN 50 MG TABLET CHEW PHENYTOIN SOD 100 MG CAPSULE PHENYTOIN SOD EXT 100 MG CAPSULE PHENYTOIN SOD EXT 200 MG CAPSULE PHENYTOIN SOD EXT 300 MG CAPSULE DILANTIN 30 MG KAPSEAL CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE 100 MG/5 ML SUSPENSION CARBAMAZEPINE 100 MG/5 ML SUSPENSION CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE 200 MG/10 ML LIQUID CARBAMAZEPINE ER 100 MG CAP July 31, 2015 Copyright 2015 Health Information Designs, LLC 73

74 Step 6 (prior therapy with a strong CYP3A4 inducer) Look back timeframe: 60 days GCN Description CARBAMAZEPINE ER 200 MG CAP CARBAMAZEPINE ER 200 MG TABLET CARBAMAZEPINE ER 300 MG CAP CARBAMAZEPINE ER 400 MG TABLET TEGRETOL XR 100 MG TABLET CARBATROL 200 MG CAPSULE SA CARBATROL 300 MG CAPSULE SA EQUETRO 100 MG CAPSULE EQUETRO 200 MG CAPSULE EQUETRO 300 MG CAPSULE PRIMIDONE 250 MG TABLET PRIMIDONE 50 MG TABLET PHENOBARBITAL 100 MG TABLET PHENOBARBITAL 100 MG TABLET PHENOBARBITAL 15 MG TABLET PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL 20 MG/5 ML ELIXIR PHENOBARBITAL 30 MG TABLET PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL 60 MG TABLET PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL 97.2 MG TABLET RIFAMPIN 150 MG CAPSULE RIFAMPIN 300 MG CAPSULE RIFABUTIN 150 MG CAPSULE XTANDI 40 MG CAPSULE Step 7 (active infection) Look back timeframe: 180 days For the list of active infection diagnosis codes that pertain to this step, see the Active Infection Diagnoses table in the previous Supporting Tables section. te: Click the hyperlink to navigate directly to the table. July 31, 2015 Copyright 2015 Health Information Designs, LLC 74

75 Clinical Edit Criteria References 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier / Gold Standard, Inc Available at Accessed on July 3, ICD-9-CM Diagnosis Codes, Volume Available at Accessed on July 31, ICD-10-CM Diagnosis Codes, Volume Available at Accessed on July 31, Actemra Prescribing Information. Genetech, Inc. South San Francisco, CA. October Cimzia Prescribing Information. UCB, Inc. Smyrna, GA. October Kineret Prescribing Information. SOBI. Stockholm, Sweden. October Ilaris Prescribing Information. vartis. East Hanover, NJ. October Orencia Prescribing Information. Bristol-Myers Squibb. Princeton, NJ. December Simponi Prescribing Information. Janssen Biotech, Inc. Horsham, PA. January Stelara Prescribing Information. Janssen Biotech, Inc. Horsham, PA. March Xeljanz Prescribing Information. Pfizer, Inc. New York, New York. May Singh JA, Furst DE, Bharat A, et al Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. Arthritis Care and Research 2012;64(5): Available at 13.Ringold S, Weiss PF, Beukelman T, et al Update of the 2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis. Arthritis and Rheumatism 2013;65(10): Available at 14.American Academy of Dermatology Work Group. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 6: guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011Jul;65(1): July 31, 2015 Copyright 2015 Health Information Designs, LLC 75

76 15.Lichtenstein GR, Hanauer SB, Sandborn WJ. Practice Parameters Committee of American College of Gastroenterology. Management of Crohn s disease in adults. Am J Gastroenterol Feb;104(2): Terdiman JP, Gruss CB, Heidelbaugh JJ, et al. AGA Institute Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute guideline on the use of thiopurines, methotrexate and anti-tnf-a biologic drugs for the induction and maintenance of remission in inflammatory Crohn s disease. Gastroenterology Dec;145(6): July 31, 2015 Copyright 2015 Health Information Designs, LLC 76

77 Publication History The Publication History records the publication iterations and revisions to this document. tes for the most current revision are also provided in the Revision tes on the first page of this document. Publication Date tes 11/20/2014 Presented to the DUR Board 11/25/2014 Initial publication and posting to website 07/31/2015 Review and update of ICD-9 and ICD-10 codes July 31, 2015 Copyright 2015 Health Information Designs, LLC 77