Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Medications Clinical Edit Information Included in this Document IR Formulations Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit ER Formulations Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 1
Non-stimulant Formulations (Except Clonidine ER) Clonidine ER Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated IR stimulants step 6 table March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 2
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Drugs Requiring Prior Authorization Label Name Drug Requiring Prior Authorization GCN ADDERALL 5MG TABLET 56970 ADDERALL 7.5MG TABLET 29007 ADDERALL 10MG TABLET 56971 ADDERALL 12.5MG TABLET 29008 ADDERALL 15MG TABLET 29009 ADDERALL 20MG TABLET 56973 ADDERALL 30MG TABLET 56972 5MG TABLET 7.5MG TABLET 10MG TABLET 12.5MG TABLET 15MG TABLET 20MG TABLET 30MG TABLET 56970 29007 56971 29008 29009 56973 56972 DESOXYN 5MG TABLET 19932 DEXMETHYLPHENIDATE 2.5MG TABLET 14973 DEXMETHYLPHENIDATE 5MG TABLET 14974 DEXMETHYLPHENIDATE 10MG TABLET 14975 DEXTROAMPHETAMINE 5MG TABLET 19881 DEXTROAMPHETAMINE 10MG TABLET 19880 DEXTROAMPHETAMINE 5MG/5ML SOLUTION 99801 EVEKEO 5MG TABLET 19822 EVEKEO 10MG TABLET 19821 FOCALIN 2.5MG TABLET 14973 FOCALIN 5MG TABLET 14974 FOCALIN 10MG TABLET 14975 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 3
Drug Requiring Prior Authorization Label Name GCN METHAMPHETAMINE 5MG TABLET 19932 METHYLIN 2.5MG CHEWABLE TABLET 22682 METHYLIN 5MG CHEWABLE TABLET 22683 METHYLIN 10MG CHEWABLE TABLET 22684 METHYLIN 5MG/5ML SOLUTION 22685 METHYLIN 10MG/5ML SOLUTION 22686 METHYLPHENIDATE 5MG/5ML SOL 22685 METHYLPHENIDATE 10MG/5ML SOL 22686 METHYLPHENIDATE 5MG TABLET 15913 METHYLPHENIDATE 10MG TABLET 15911 METHYLPHENIDATE 20MG TABLET 15920 PROCENTRA 5MG/5ML SOLUTION 99801 RITALIN 5MG TABLET 15913 RITALIN 10MG TABLET 15911 RITALIN 20MG TABLET 15920 ZENZEDI 2.5MG TABLET 34734 ZENZEDI 5MG TABLET 19881 ZENZEDI 7.5MG TABLET 34735 ZENZEDI 10MG TABLET 19880 ZENZEDI 15MG TABLET 19885 ZENZEDI 20MG TABLET 36463 ZENZEDI 30MG TABLET 36464 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 4
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Clinical Edit Criteria Logic 1. Is the client less than (<) 3 years of age? [] Yes Deny [] No Go to #2 2. Does the client have a history of substance abuse in the last 365 days? [] Yes Deny [] No Go to #3 3. Is the request for greater than (>) the Texas Department of Family and Protective Services (DFPS) maximum recommended daily dose? [] Yes Deny [] No Go to #4 4. Does the client have a paid claim for another IR stimulant in the past 14 days? [] Yes Deny [] No Go to #5 5. Is the client less than (<) 6 years of age? [] Yes Go to #6 [] No Go to #7 6. Is the request for amphetamine salts, dextroamphetamine, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi? [] Yes Approve (365 days) [] No Deny 7. Is the client greater than or equal to ( ) 19 years of age? [] Yes Go to #8 [] No Approve (365 days) 8. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [] Yes Approve (365 days) [] No Go to #9 9. Does the client have a diagnosis of narcolepsy in the past 730 days? [] Yes Go to #10 [] No Deny 10. Is the request for dexmethylphenidate or methamphetamine? [] Yes Deny [] No Approve (365 days) March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 5
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Clinical Edit Criteria Logic Diagram The IR Formulations Clinical Edit Criteria Logic Diagram is shown on the following page. March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 6
No No Yes No Yes Yes Yes Yes No No Texas Prior Authorization Program Clinical Edits Step 1 Step 2 Step 3 Step 4 Is the client less than 3 years of age? Does the client have a history of substance abuse in the last 365 days? Is the request for greater than the TX DFPS maximum daily dose? Does the client have a paid claim for another IR stimulant in the past 14 days? Deny Deny Deny Deny Step 5 Is the client less than 6 years of age? Step 6 Is the request for amphetamine salts, dextroamphetamine, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi? Step 7 Is the client greater than or equal to 19 years of age? Approve (365 days) Step 10 Step 9 Step 8 Deny Yes Is the request for dexmethylphenidate or methamphetamine? Yes Does the client have a diagnosis of narcolepsy in the last 730 days? No Does the client have a diagnosis of ADD/ADHD in the last 730 days? Approve (365 days) Approve (365 days) Deny March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 7
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) IR Formulations Clinical Edit Criteria Supporting Tables Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses ICD-9 Code Description 30400 OPIOID DEPENDENCE-UNSPEC 30401 OPIOID DEPENDENCE-CONTIN 30402 OPIOID DEPENDENCE-EPISOD 30403 OPIOID DEPENDENCE-REMISS 30410 SEDATIVE,HYPNOTIC OR ANXIOLYTIC DEPENDENCE UNSPECIFIED 30411 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, CONTINUOUS 30412 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC 30413 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION 30420 COCAINE DEPEND-UNSPEC 30421 COCAINE DEPEND-CONTIN 30422 COCAINE DEPEND-EPISODIC 30423 COCAINE DEPEND-REMISS 30430 CANNABIS DEPEND-UNSPEC 30431 CANNABIS DEPEND-CONTIN 30432 CANNABIS DEPEND-EPISODIC 30433 CANNABIS DEPEND-REMISS 30440 AMPHETAMIN DEPEND-UNSPEC 30441 AMPHETAMIN DEPEND-CONTIN 30442 AMPHETAMIN DEPEND-EPISOD 30443 AMPHETAMIN DEPEND-REMISS 30450 HALLUCINOGEN DEP-UNSPEC 30451 HALLUCINOGEN DEP-CONTIN 30452 HALLUCINOGEN DEP-EPISOD 30453 HALLUCINOGEN DEP-REMISS 30460 DRUG DEPEND NEC-UNSPEC 30461 DRUG DEPEND NEC-CONTIN 30462 DRUG DEPEND NEC-EPISODIC March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 8
Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses 30463 DRUG DEPEND NEC-IN REM 30470 OPIOID/OTHER DEP-UNSPEC 30471 OPIOID/OTHER DEP-CONTIN 30472 OPIOID/OTHER DEP-EPISOD 30473 OPIOID/OTHER DEP-REMISS 30480 COMB DRUG DEP NEC-UNSPEC 30481 COMB DRUG DEP NEC-CONTIN 30482 COMB DRUG DEP NEC-EPISOD 30483 COMB DRUG DEP NEC-REMISS 30490 DRUG DEPEND NOS-UNSPEC 30491 DRUG DEPEND NOS-CONTIN 30492 DRUG DEPEND NOS-EPISODIC 30493 DRUG DEPEND NOS-REMISS 30500 ALCOHOL ABUSE-UNSPEC 30501 ALCOHOL ABUSE-CONTINUOUS 30502 ALCOHOL ABUSE-EPISODIC 30503 ALCOHOL ABUSE-IN REMISS 30520 CANNABIS ABUSE-UNSPEC 30521 CANNABIS ABUSE-CONTIN 30522 CANNABIS ABUSE-EPISODIC 30523 CANNABIS ABUSE-IN REMISS 30530 HALLUCINOG ABUSE-UNSPEC 30531 HALLUCINOG ABUSE-CONTIN 30532 HALLUCINOG ABUSE-EPISOD 30533 HALLUCINOG ABUSE-REMISS 30540 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED 30541 SEDATIVE, HYPNOTIC OR ANXIOLYTIC, ABUSE, CONTINUOUS 30542 SEDATIVE, HYPNOTIC, OR ANXIOLYTIC ABUSE, EPISODIC 30543 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION 30550 OPIOID ABUSE-UNSPEC 30551 OPIOID ABUSE-CONTINUOUS 30552 OPIOID ABUSE-EPISODIC 30553 OPIOID ABUSE-IN REMISS 30560 COCAINE ABUSE-UNSPEC 30561 COCAINE ABUSE-CONTINUOUS 30562 COCAINE ABUSE-EPISODIC March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 9
Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses 30563 COCAINE ABUSE-IN REMISS 30570 AMPHETAMINE ABUSE-UNSPEC 30571 AMPHETAMINE ABUSE-CONTIN 30572 AMPHETAMINE ABUSE-EPISOD 30573 AMPHETAMINE ABUSE-REMISS 30590 DRUG ABUSE NEC-UNSPEC 30591 DRUG ABUSE NEC-CONTIN 30592 DRUG ABUSE NEC-EPISODIC 30593 DRUG ABUSE NEC-IN REMISS ICD-10 Code F1010 F10120 F10121 F10129 F1014 F10150 F10151 F10159 F10180 F10181 F10182 F10188 F1019 F1020 F10220 F10221 F10229 F10230 F10231 F10232 F10239 F1024 Description ALCOHOL ABUSE UNCOMPLICATED ALCOHOL ABUSE WITH INTOXICATION UNCOMPLICATED ALCOHOL ABUSE WITH INTOXICATION DELIRIUM ALCOHOL ABUSE WITH INTOXICATION UNSPECIFIED ALCOHOL ABUSE WITH ALCOHOL-INDUCED MOOD ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC WITH DELUSIONS ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC WITH HALLUCINATIONS ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC UNSPECIFIED ALCOHOL ABUSE WITH ALCOHOL-INDUCED ANXIETY ALCOHOL ABUSE WITH ALCOHOL-INDUCED SEXUAL DYSFUNCTION ALCOHOL ABUSE WITH ALCOHOL-INDUCED SLEEP ALCOHOL ABUSE WITH OTHER ALCOHOL-INDUCED ALCOHOL ABUSE WITH UNSPECIFIED ALCOHOL-INDUCED ALCOHOL DEPENDENCE UNCOMPLICATED ALCOHOL DEPENDENCE WITH INTOXICATION UNCOMPLICATED ALCOHOL DEPENDENCE WITH INTOXICATION DELIRIUM ALCOHOL DEPENDENCE WITH INTOXICATION UNSPECIFIED ALCOHOL DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED ALCOHOL DEPENDENCE WITH WITHDRAWAL DELIRIUM ALCOHOL DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE ALCOHOL DEPENDENCE WITH WITHDRAWAL UNSPECIFIED ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED MOOD March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 10
Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses F10250 F10251 F10259 F1026 F1027 F10280 F10281 F10282 F10288 F1029 F1110 F11120 F11121 F11122 F11129 F1114 F11150 F11151 F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11220 F11221 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC WITH DELUSIONS ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC WITH HALLUCINATIONS ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC UNSPECIFIED ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PERSISTING AMNESTIC ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PERSISTING DEMENTIA ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED ANXIETY ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED SEXUAL DYSFUNCTION ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED SLEEP ALCOHOL DEPENDENCE WITH OTHER ALCOHOL-INDUCED ALCOHOL DEPENDENCE WITH UNSPECIFIED ALCOHOL-INDUCED OPIOID ABUSE UNCOMPLICATED OPIOID ABUSE WITH INTOXICATION UNCOMPLICATED OPIOID ABUSE WITH INTOXICATION DELIRIUM OPIOID ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OPIOID ABUSE WITH INTOXICATION UNSPECIFIED OPIOID ABUSE WITH OPIOID-INDUCED MOOD OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC WITH DELUSIONS OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC WITH HALLUCINATIONS OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC UNSPECIFIED OPIOID ABUSE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION OPIOID ABUSE WITH OPIOID-INDUCED SLEEP OPIOID ABUSE WITH OTHER OPIOID-INDUCED OPIOID ABUSE WITH UNSPECIFIED OPIOID-INDUCED OPIOID DEPENDENCE, UNCOMPLICATED OPIOID DEPENDENCE, IN REMISSION OPIOID DEPENDENCE WITH INTOXICATION UNCOMPLICATED OPIOID DEPENDENCE WITH INTOXICATION DELIRIUM March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 11
Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses F11222 F11229 F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288 F1129 F1210 F12120 F12121 F12122 F12129 F12150 F12151 F12159 F12180 F12188 F1219 F1220 F1221 F12220 F12221 F12222 F12229 F12250 OPIOID DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OPIOID DEPENDENCE WITH INTOXICATION UNSPECIFIED OPIOID DEPENDENCE WITH WITHDRAWAL OPIOID DEPENDENCE WITH OPIOID-INDUCED MOOD OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC WITH DELUSIONS OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC WITH HALLUCINATIONS OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC UNSPECIFIED OPIOID DEPENDENCE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION OPIOID DEPENDENCE WITH OPIOID-INDUCED SLEEP OPIOID DEPENDENCE WITH OTHER OPIOID-INDUCED OPIOID DEPENDENCE WITH UNSPECIFIED OPIOID-INDUCED CANNABIS ABUSE UNCOMPLICATED CANNABIS ABUSE WITH INTOXICATION UNCOMPLICATED CANNABIS ABUSE WITH INTOXICATION DELIRIUM CANNABIS ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE CANNABIS ABUSE WITH INTOXICATION UNSPECIFIED CANNABIS ABUSE WITH PSYCHOTIC WITH DELUSIONS CANNABIS ABUSE WITH PSYCHOTIC WITH HALLUCINATIONS CANNABIS ABUSE WITH PSYCHOTIC UNSPECIFIED CANNABIS ABUSE WITH CANNABIS-INDUCED ANXIETY CANNABIS ABUSE WITH OTHER CANNABIS-INDUCED CANNABIS ABUSE WITH UNSPECIFIED CANNABIS-INDUCED CANNABIS DEPENDENCE, UNCOMPLICATED CANNABIS DEPENDENCE, IN REMISSION CANNABIS DEPENDENCE WITH INTOXICATION UNCOMPLICATED CANNABIS DEPENDENCE WITH INTOXICATION DELIRIUM CANNABIS DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE CANNABIS DEPENDENCE WITH INTOXICATION UNSPECIFIED CANNABIS DEPENDENCE WITH PSYCHOTIC WITH DELUSIONS March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 12
F12251 F12259 F12280 F12288 F1229 F1310 F13120 F13121 F13129 F1314 F13150 F13151 F13159 F13180 F13181 F13182 F13188 F1319 F1320 F1321 F13220 F13221 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses CANNABIS DEPENDENCE WITH PSYCHOTIC WITH HALLUCINATIONS CANNABIS DEPENDENCE WITH PSYCHOTIC UNSPECIFIED CANNABIS DEPENDENCE WITH CANNABIS-INDUCED ANXIETY CANNABIS DEPENDENCE WITH OTHER CANNABIS-INDUCED CANNABIS DEPENDENCE WITH UNSPECIFIED CANNABIS-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION DELIRIUM SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED MOOD SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC WITH DELUSIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC WITH HALLUCINATIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED ANXIETY SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEXUAL DYSFUNCTION SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SLEEP SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH OTHER SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE IN REMISSION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION DELIRIUM March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 13
F13229 F13230 F13231 F13232 F13239 F1324 F13250 F13251 F13259 F1326 F1327 F13280 F13281 F13282 F13288 F1329 F1410 F14120 F14121 F14122 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL DELIRIUM SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED MOOD SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC UNCOMPLICATED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC WITH HALLUCINATIONS SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING AMNESTIC SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING DEMENTIA SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED ANXIETY SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEXUAL DYSFUNCTION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SLEEP SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH OTHER SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED COCAINE ABUSE UNCOMPLICATED COCAINE ABUSE WITH INTOXICATION UNCOMPLICATED COCAINE ABUSE WITH INTOXICATION WITH DELIRIUM COCAINE ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 14
F14129 F1414 F14150 F14151 F14159 F14180 F14181 F14182 F14188 F1419 F1420 F14220 F14221 F14222 F14229 F1423 F1424 F14250 F14251 F14259 F14280 F14281 F14282 F14288 F1429 F1510 F15120 F15121 F15122 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses COCAINE ABUSE WITH INTOXICATION UNSPECIFIED COCAINE ABUSE WITH COCAINE-INDUCED MOOD COCAINE ABUSE WITH COCAINE-INDUCED PSYCHOTIC WITH DELUSIONS COCAINE ABUSE WITH COCAINE-INDUCED PSYCHOTIC WITH HALLUCINATIONS COCAINE ABUSE WITH COCAINE-INDUCED PSYCHOTIC UNSPECIFIED COCAINE ABUSE WITH COCAINE-INDUCED ANXIETY COCAINE ABUSE WITH COCAINE-INDUCED SEXUAL DYSFUNCTION COCAINE ABUSE WITH COCAINE-INDUCED SLEEP COCAINE ABUSE WITH OTHER COCAINE-INDUCED COCAINE ABUSE WITH UNSPECIFIED COCAINE-INDUCED COCAINE DEPENDENCE UNCOMPLICATED COCAINE DEPENDENCE WITH INTOXICATION UNCOMPLICATED COCAINE DEPENDENCE WITH INTOXICATION DELIRIUM COCAINE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE COCAINE DEPENDENCE WITH INTOXICATION UNSPECIFIED COCAINE DEPENDENCE WITH WITHDRAWAL COCAINE DEPENDENCE WITH COCAINE-INDUCED MOOD COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC WITH DELUSIONS COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC WITH HALLUCINATIONS COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC UNSPECIFIED COCAINE DEPENDENCE WITH COCAINE-INDUCED ANXIETY COCAINE DEPENDENCE WITH COCAINE-INDUCED SEXUAL DYSFUNCTION COCAINE DEPENDENCE WITH COCAINE-INDUCED SLEEP COCAINE DEPENDENCE WITH OTHER COCAINE-INDUCED COCAINE DEPENDENCE WITH UNSPECIFIED COCAINE-INDUCED OTHER STIMULANT ABUSE UNCOMPLICATED OTHER STIMULANT ABUSE WITH INTOXICATION UNCOMPLICATED OTHER STIMULANT ABUSE WITH INTOXICATION DELIRIUM OTHER STIMULANT ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 15
F15129 F1514 F15150 F15151 F15159 F15180 F15181 F15182 F15188 F1519 F1520 F15220 F15221 F15222 F15229 F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282 F15288 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses OTHER STIMULANT ABUSE WITH INTOXICATION UNSPECIFIED OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED MOOD OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED PSYCHOTIC WITH DELUSIONS OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED PSYCHOTIC UNSPECIFIED OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED ANXIETY OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED SEXUAL DYSFUNCTION OTHER STIMULANT ABUSE WITH STIMULANT-INDUCED SLEEP OTHER STIMULANT ABUSE WITH OTHER STIMULANT-INDUCED OTHER STIMULANT ABUSE WITH UNSPECIFIED STIMULANT-INDUCED OTHER STIMULANT DEPENDENCE UNCOMPLICATED OTHER STIMULANT DEPENDENCE WITH INTOXICATION UNCOMPLICATED OTHER STIMULANT DEPENDENCE WITH INTOXICATION DELIRIUM OTHER STIMULANT DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OTHER STIMULANT DEPENDENCE WITH INTOXICATION UNSPECIFIED OTHER STIMULANT DEPENDENCE WITH WITHDRAWAL OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED MOOD OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC WITH DELUSIONS OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC UNSPECIFIED OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED ANXIETY OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SEXUAL DYSFUNCTION OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SLEEP OTHER STIMULANT DEPENDENCE WITH OTHER STIMULANT-INDUCED March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 16
F1529 F1610 F16120 F16121 F16122 F16129 F1614 F16150 F16151 F16159 F16180 F16183 F16188 F1619 F1620 F16220 F16221 F16229 F1624 F16250 F16251 F16259 F16280 F16283 F16288 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses OTHER STIMULANT DEPENDENCE WITH UNSPECIFIED STIMULANT- INDUCED HALLUCINOGEN ABUSE UNCOMPLICATED HALLUCINOGEN ABUSE WITH INTOXICATION UNCOMPLICATED HALLUCINOGEN ABUSE WITH INTOXICATION WITH DELIRIUM HALLUCINOGEN ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE HALLUCINOGEN ABUSE WITH INTOXICATION UNSPECIFIED HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED MOOD HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH DELUSIONS HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH HALLUCINATIONS HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED PSYCHOTIC UNSPECIFIED HALLUCINOGEN ABUSE WITH HALLUCINOGEN-INDUCED ANXIETY HALLUCINOGEN ABUSE WITH HALLUCINOGEN PERSISTING PERCEPTION (FLASHBACKS) HALLUCINOGEN ABUSE WITH OTHER HALLUCINOGEN-INDUCED HALLUCINOGEN ABUSE WITH UNSPECIFIED HALLUCINOGEN- INDUCED HALLUCINOGEN DEPENDENCE UNCOMPLICATED HALLUCINOGEN DEPENDENCE WITH INTOXICATION UNCOMPLICATED HALLUCINOGEN DEPENDENCE WITH INTOXICATION WITH DELIRIUM HALLUCINOGEN DEPENDENCE WITH INTOXICATION UNSPECIFIED HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED MOOD HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH DELUSIONS HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC WITH HALLUCINATIONS HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC UNSPECIFIED HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED ANXIETY HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN PERSISTING PERCEPTION (FLASHBACKS) HALLUCINOGEN DEPENDENCE WITH OTHER HALLUCINOGEN- INDUCED March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 17
F1629 F1810 F18120 F18121 F18129 F1814 F18150 F18151 F18159 F1817 F18180 F18188 F1819 F1820 F18220 F18221 F18229 F1824 F18250 F18251 F18259 F1827 F18280 F18288 F1829 F1910 F19120 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses HALLUCINOGEN DEPENDENCE WITH UNSPECIFIED HALLUCINOGEN- INDUCED INHALANT ABUSE UNCOMPLICATED INHALANT ABUSE WITH INTOXICATION UNCOMPLICATED INHALANT ABUSE WITH INTOXICATION DELIRIUM INHALANT ABUSE WITH INTOXICATION UNSPECIFIED INHALANT ABUSE WITH INHALANT-INDUCED MOOD INHALANT ABUSE WITH INHALANT-INDUCED PSYCHOTIC WITH DELUSIONS INHALANT ABUSE WITH INHALANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS INHALANT ABUSE WITH INHALANT-INDUCED PSYCHOTIC UNSPECIFIED INHALANT ABUSE WITH INHALANT-INDUCED DEMENTIA INHALANT ABUSE WITH INHALANT-INDUCED ANXIETY INHALANT ABUSE WITH OTHER INHALANT-INDUCED INHALANT ABUSE WITH UNSPECIFIED INHALANT-INDUCED INHALANT DEPENDENCE, UNCOMPLICATED INHALANT DEPENDENCE WITH INTOXICATION UNCOMPLICATED INHALANT DEPENDENCE WITH INTOXICATION DELIRIUM INHALANT DEPENDENCE WITH INTOXICATION UNSPECIFIED INHALANT DEPENDENCE WITH INHALANT-INDUCED MOOD INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC WITH DELUSIONS INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC WITH HALLUCINATIONS INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC, UNSPECIFIED INHALANT DEPENDENCE WITH INHALANT-INDUCED DEMENTIA INHALANT DEPENDENCE WITH INHALANT-INDUCED ANXIETY INHALANT DEPENDENCE WITH OTHER INHALANT-INDUCED INHALANT DEPENDENCE WITH UNSPECIFIED INHALANT-INDUCED OTHER PSYCHOACTIVE SUBSTANCE ABUSE UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION UNCOMPLICATED March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 18
F19121 F19122 F19129 F1914 F19150 F19151 F19159 F1916 F1917 F19180 F19181 F19182 F19188 F1919 F1920 F19220 F19221 F19222 F19229 F19230 F19231 F19232 F19239 Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCES OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH INTOXICATION UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH DELUSIONS OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING AMNESTIC OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING DEMENTIA OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED ANXIETY OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SEXUAL DYSFUNCTION OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SLEEP OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH OTHER PSYCHOACTIVE SUBSTANCE-INDUCED OTHER PSYCHOACTIVE SUBSTANCE ABUSE WITH UNSPECIFIED PSYCHOACTIVE SUBSTANCE-INDUCED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION, UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL DELIRIUM OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL UNSPECIFIED March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 19
Step 2 (history of substance abuse) Look back timeframe: 365 days History of Substance Abuse Diagnoses F1924 F19250 F19251 F19259 F1926 F1927 F19280 F19281 F19282 F19288 F1929 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH DELUSIONS OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC WITH HALLUCINATIONS OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING AMNESTIC OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING DEMENTIA OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED ANXIETY OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SEXUAL DYSFUNCTION OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED SLEEP OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH OTHER PSYCHOACTIVE SUBSTANCE-INDUCED OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH UNSPECIFIED PSYCHOACTIVE SUBSTANCE-INDUCED March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 20
Active Ingredient Drug (brand) Initial Dosage Step 3 (Texas DFPS maximum recommended dose) TX DFPS Recommended Dosage Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents AMPHETAMINE/ DEXTROAMPHETAMINE SALTS ADDERALL EVEKEO Age 3-5 years: 2.5mg/day Age 6 years: 5-10mg/day >50kg: 60mg/day Approved for children 3 years and older: 40mg/day DEXMETHYLPHENIDATE FOCALIN 2.5mg twice daily 50mg/day Approved for children 6 years and older: 20mg/day DEXTROAMPHETAMINE DEXEDRINE Age 3-5 years: 2.5mg/day Age 6 years: 5mg twice daily >50kg: 60mg/day Approved for children 6 years and older: 40mg/day METHAMPHETAMINE DESOXYN 5mg daily N/A Approved for children 6 years and older: 25mg/day METHYLPHENIDATE RITALIN METHYLIN Age 3-5 years: 2.5mg twice daily Age 6 years: 5mg twice daily Age 3-5 years: 22.5mg/day >50kg: 100mg/day Approved for children 6 years and older: 60mg/day March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 21
Label Name Step 4 (paid claim for another IR stimulant) Look back timeframe: 14 days IR Stimulants GCN ADDERALL 5MG TABLET 56970 ADDERALL 7.5MG TABLET 29007 ADDERALL 10MG TABLET 56971 ADDERALL 12.5MG TABLET 29008 ADDERALL 15MG TABLET 29009 ADDERALL 20MG TABLET 56973 ADDERALL 30MG TABLET 56972 5MG TABLET 56970 7.5MG TABLET 29007 10MG TABLET 56971 12.5MG TABLET 29008 15MG TABLET 29009 20MG TABLET 56973 30MG TABLET 56972 DESOXYN 5MG TABLET 19932 DEXMETHYLPHENIDATE 2.5MG TABLET 14973 DEXMETHYLPHENIDATE 5MG TABLET 14974 DEXMETHYLPHENIDATE 10MG TABLET 14975 DEXTROAMPHETAMINE 5MG TABLET 19881 DEXTROAMPHETAMINE 10MG TABLET 19880 DEXTROAMPHETAMINE 5MG/5ML 99801 EVEKEO 5MG TABLET 19822 EVEKEO 10MG TABLET 19821 FOCALIN 2.5MG TABLET 14973 FOCALIN 5MG TABLET 14974 FOCALIN 10MG TABLET 14975 METHAMPHETAMINE 5MG TABLET 19932 METHYLIN 2.5MG CHEWABLE TABLET 22682 METHYLIN 5MG CHEWABLE TABLET 22683 METHYLIN 10MG CHEWABLE TABLET 22684 METHYLIN 5MG/5ML SOLUTION 22685 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 22
Step 4 (paid claim for another IR stimulant) Look back timeframe: 14 days IR Stimulants Label Name GCN METHYLIN 10MG/5ML SOLUTION 22686 METHYLPHENIDATE 5MG/5ML SOLUTION 22685 METHYLPHENIDATE 10MG/ML 22686 METHYLPHENIDATE 5MG TABLET 15913 METHYLPHENIDATE 10MG TABLET 15911 METHYLPHENIDATE 20MG TABLET 15920 PROCENTRA 5MG/5ML SOLUTION 99801 RITALIN 5MG TABLET 15913 RITALIN 10MG TABLET 15911 RITALIN 20MG TABLET 15920 ZENZEDI 2.5MG TABLET 34734 ZENZEDI 5MG TABLET 19881 ZENZEDI 7.5MG TABLET 34735 ZENZEDI 10MG TABLET 19880 ZENZEDI 15MG TABLET 19885 ZENZEDI 20MG TABLET 36463 ZENZEDI 30MG TABLET 36464 Step 6 (amphetamine salts immediate release tablets, dextroamphetamine immediate release tablets, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi) Label Name GCN ADDERALL 5MG TABLET 56970 ADDERALL 7.5MG TABLET 29007 ADDERALL 10MG TABLET 56971 ADDERALL 12.5MG TABLET 29008 ADDERALL 15MG TABLET 29009 ADDERALL 20MG TABLET 56973 ADDERALL 30MG TABLET 56972 5MG TABLET 56970 7.5MG TABLET 29007 10MG TABLET 56971 12.5MG TABLET 29008 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 23
Step 6 (amphetamine salts immediate release tablets, dextroamphetamine immediate release tablets, dexmethylphenidate, methylphenidate, Procentra, or Zenzedi) Label Name GCN 15MG TABLET 29009 20MG TABLET 56973 30MG TABLET 56972 DEXTROAMPHETAMINE 5MG TABLET 19881 DEXTROAMPHETAMINE 10MG TABLET 19880 DEXMETHYLPHENIDATE 2.5MG TABLET 14973 DEXMETHYLPHENIDATE 5MG TABLET 14974 DEXMETHYLPHENIDATE 10MG TABLET 14975 EVEKEO 5MG TABLET 19822 EVEKEO 10MG TABLET 19821 FOCALIN 2.5MG TABLET 14973 FOCALIN 5MG TABLET 14974 FOCALIN 10MG TABLET 14975 METHYLIN 2.5MG CHEWABLE TABLET 22682 METHYLIN 5MG CHEWABLE TABLET 22683 METHYLIN 10MG CHEWABLE TABLET 22684 METHYLIN 5MG/5ML SOLUTION 22685 METHYLIN 10MG/5ML SOLUTION 22686 METHYLPHENIDATE 5MG/5ML SOLUTION 22685 METHYLPHENIDATE 10MG/ML 22686 METHYLPHENIDATE 5MG TABLET 15913 METHYLPHENIDATE 10MG TABLET 15911 METHYLPHENIDATE 20MG TABLET 15920 PROCENTRA 5MG/5ML SOLUTION 99801 RITALIN 5MG TABLET 15913 RITALIN 10MG TABLET 15911 RITALIN 20MG TABLET 15920 ZENZEDI 2.5MG TABLET 34734 ZENZEDI 5MG TABLET 19881 ZENZEDI 7.5MG TABLET 34735 ZENZEDI 10MG TABLET 19880 ZENZEDI 15MG TABLET 19885 ZENZEDI 20MG TABLET 36463 ZENZEDI 30MG TABLET 36464 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 24
ICD-9 Code 31400 Description Step 8 (diagnosis of ADD or ADHD) Look back timeframe: 730 days ADD/ADHD Diagnoses ATTENTION DEFICIT WITHOUT MENTION OF HYPERACTIVITY 31401 ATTENTION DEFICIT WITH HYPERACTIVITY ICD-10 Code F900 F901 F902 F908 F909 Description ATTENTION-DEFICIT HYPERACTIVITY, PREDOMINANTLY INATTENTIVE TYPE ATTENTION-DEFICIT HYPERACTIVITY, PREDOMINANTLY HYPERACTIVE TYPE ATTENTION-DEFICIT HYPERACTIVITY, COMBINED TYPE ATTENTION-DEFICIT HYPERACTIVITY, OTHER TYPE ATTENTION-DEFICIT HYPERACTIVITY, UNSPECIFIED TYPE ICD-9 Code Description Step 9 (diagnosis of narcolepsy) Required diagnosis: 1 Look back timeframe: 730 days Narcolepsy Diagnoses 34700 NARCOLEPSY WITHOUT CATAPLEXY 34701 NARCOLEPSY WITH CATAPLEXY 34710 34711 ICD-10 Code G47419 G47411 G47429 G47421 NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH CATAPLEXY Description NARCOLEPSY WITHOUT CATAPLEXY NARCOLEPSY WITH CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE WITH CATAPLEXY March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 25
Step 10 (dexmethylphenidate immediate release or methamphetamine) Dexmethylphenidate Immediate Release Drugs/Methamphetamines Label Name GCN DEXMETHYLPHENIDATE 2.5MG TABLET 14973 DEXMETHYLPHENIDATE 5MG TABLET 14974 DEXMETHYLPHENIDATE 10MG TABLET 14975 FOCALIN 2.5MG TABLET 14973 FOCALIN 5MG TABLET 14974 FOCALIN 10MG TABLET 14975 METHAMPHETAMINE 5MG TABLET 19932 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 26
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Drugs Requiring Prior Authorization Label Name Drugs Requiring Prior Authorization GCN ADDERALL XR 5MG CAPSULE 17459 ADDERALL XR 10MG CAPSULE 14635 ADDERALL XR 15MG CAPSULE 17468 ADDERALL XR 20MG CAPSULE 14636 ADDERALL XR 25MG CAPSULE 17469 ADDERALL XR 30MG CAPSULE 14637 5MG EXTENDED- 10MG EXTENDED- 15MG EXTENDED- 20MG EXTENDED- 25MG EXTENDED- 30MG EXTENDED- 17459 14635 17468 14636 17469 14637 APTENSIO XR 10MG CAPSULE 97234 APTENSIO XR 15MG CAPSULE 97235 APTENSIO XR 20MG CAPSULE 97236 APTENSIO XR 30MG CAPSULE 97237 APTENSIO XR 40MG CAPSULE 97238 APTENSIO XR 50MG CAPSULE 97239 APTENSIO XR 60MG CAPSULE 97240 CONCERTA ER 18MG TABLET 12567 CONCERTA ER 27MG TABLET 17123 CONCERTA ER 36MG TABLET 12568 CONCERTA ER 54MG TABLET 12248 DAYTRANA 10MG/9HR PATCH 26801 DAYTRANA 15MG/9HR PATCH 26802 DAYTRANA 20MG/9HR PATCH 26803 DAYTRANA 30MG/9HR PATCH 26804 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 27
Label Name Drugs Requiring Prior Authorization GCN DEXEDRINE SPANSULE 5MG 19852 DEXEDRINE SPANSULE 10MG 19850 DEXEDRINE SPANSULE 15MG 19851 DEXMETHYLPHENIDATE 15MG EXTENDED DEXMETHYLPHENIDATE 30MG EXTENDED DEXMETHYLPHENIDATE 40MG EXTENDED DEXTROAMPHETAMINE 5MG EXTENDED- DEXTROAMPHETAMINE 10MG EXTENDED- DEXTROAMPHETAMINE 15MG EXTENDED- 97111 28035 28933 28933 19850 19851 FOCALIN XR 5MG CAPSULE 24733 FOCALIN XR 10MG CAPSULE 24734 FOCALIN XR 15MG CAPSULE 97111 FOCALIN XR 20MG CAPSULE 24735 FOCALIN XR 25MG CAPSULE 30305 FOCALIN XR 30MG CAPSULE 28035 FOCALIN XR 35MG CAPSULE 30306 FOCALIN XR 40MG CAPSULE 28933 METADATE CD 10MG CAPSULE 20384 METADATE CD 20MG CAPSULE 20385 METADATE CD 30MG CAPSULE 20386 METADATE CD 40MG CAPSULE 26734 METADATE CD 50MG CAPSULE 26735 METADATE CD 60MG CAPSULE 26736 METADATE ER 10MG TABLET SA 93075 METADATE ER 20MG TABLET ER 16180 METHYLPHENIDATE 20MG EXTENDED- METHYLPHENIDATE 30MG EXTENDED- METHYLPHENIDATE 40MG EXTENDED- METHYLPHENIDATE CD 10MG EXTENDED- METHYLPHENIDATE CD 20MG EXTENDED- METHYLPHENIDATE CD 30MG EXTENDED- 20387 20388 20391 20384 20385 20386 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 28
Label Name METHYLPHENIDATE CD 40MG EXTENDED- METHYLPHENIDATE CD 50MG EXTENDED- METHYLPHENIDATE CD 60MG EXTENDED- METHYLPHENIDATE 18MG EXTENDED- RELEASE TABLET METHYLPHENDIATE 20MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 27MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 36MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 54MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 20MG SUSTAINED- RELEASE TABLET Drugs Requiring Prior Authorization GCN 26734 26735 26736 12567 16180 17123 12568 12248 16180 QUILLIVANT XR 25MG/5ML SUSP 33887 RITALIN LA 10MG CAPSULE 21763 RITALIN LA 20MG CAPSULE 20387 RITALIN LA 30MG CAPSULE 20388 RITALIN LA 40MG CAPSULE 20391 RITALIN SR 20MG TABLET 16180 VYVANSE 10MG CAPSULE 37674 VYVANSE 20MG CAPSULE 99366 VYVANSE 30MG CAPSULE 98071 VYVANSE 40MG CAPSULE 99367 VYVANSE 50MG CAPSULE 98072 VYVANSE 60MG CAPSULE 99368 VYVANSE 70MG CAPSULE 98073 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 29
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Clinical Edit Criteria Logic 1. Is the client less than (<) 6 years of age? [ ] Yes Deny [ ] No Go to #2 2. Does the client have a history of substance abuse in the last 365 days? [ ] Yes Deny [ ] No Go to #3 3. Is the request for greater than (>) the Texas Department of Family and Protective Services (DFPS) maximum recommended dose? [] Yes Deny [] No Go to #4 4. Does the client have a paid claim for another ER stimulant in the past 14 days? [ ] Yes Deny [ ] No Go to #5 5. Is the client greater than or equal to ( ) 19 years of age? [ ] Yes Go to #6 [ ] No Approve (365 days) 6. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [ ] Yes Approve (365 days) [ ] No Go to #7 7. Does the client have a diagnosis of narcolepsy in the last 730 days? [ ] Yes Go to #8 [ ] No Deny 8. Is the request for methylphenidate extended release tablets, methylphenidate sustained release tablets, or dextroamphetamine extended release capsules? [ ] Yes Approve (365 days) [ ] No Deny March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 30
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Clinical Edit Criteria Logic Diagram The ER Formulations Clinical Edit Criteria Logic Diagram is shown on the following page. March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 31
No No No Yes Yes Yes Yes No Texas Prior Authorization Program Clinical Edits Step 1 Step 2 Step 3 Step 4 Is the client less than 6 years of age? Does the client have a history of substance abuse in the last 365 days? Is the request for greater than the TX DFPS maximum recommended dose? Does the client have a paid claim for another ER stimulant in the past 14 days? Deny Step 5 Deny Deny Deny Is the client greater than Approve or equal to 19 years of (365 days) age? Step 6 Does the client have a diagnosis of ADD/ADHD in the last 730 days? Approve (365 days) Step 8 Step 7 Approve (365 days) Yes Is the request for methylphenidate ER, methylphenidate SR, or dextroamphetamine ER? Yes Does the client have a diagnosis of narcolepsy in the last 730 days? Deny Deny March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 32
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) ER Formulations Clinical Edit Criteria Supporting Tables Step 2 (history of substance abuse) Look back timeframe: 365 days For the list of diagnosis codes that pertain to this step, see the History of Substance Abuse Diagnoses table in the previous Supporting Tables section. March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 33
Active Ingredient Drug (brand) Initial Dosage Step 3 (Texas DFPS maximum recommended dose) TX DFPS Recommended Dosage Literature Based Maximum Dosage FDA Approved Maximum Dosage for Children and Adolescents AMPHETAMINE/ DEXTROAMPHETAMINE SALTS ADDERALL XR Age 6-12 years: 5-10mg/day Age 13 years: 10mg/day >50kg: 60mg/day Approved for children 6 years and older: 30mg/day DEXMETHYLPHENIDATE FOCALIN XR 5mg/day 50mg/day Approved for children 6 years and older: 30mg/day DEXTROAMPHETAMINE DEXEDRINE SPANSULE Age 6 years: 5mg/day >50kg: 60mg/day Approved for children 6 years and older: 40mg/day LISDEXAMFETAMINE VYVANSE 30mg/day 70mg/day Approved for children 6 years and older: 70mg/day METHYLPHENIDATE RITALIN SR RITALIN LA METADATE ER METADATE CD METHYLIN ER APTENSIO XR 20mg/day 10mg/day CONCERTA 18mg/day 108mg/day DAYTRANA TD 10mg/day 30mg/day Age 3-5 years: 22.5mg/day >50kg: 100mg/day Age 3-5 years: 22.5mg/day >50kg: 100mg/day Approved for children 6 years and older: 60mg/day Approved for children 6 years and older: 60mg/day Age 6-12 years: 54mg/day Age 13-17 years: lesser of 72mg/day or 2mg/kg/day Approved for children 6 years and older: 30mg/day March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 34
Label Name Step 4 (paid claim for another ER stimulant) Look back timeframe: 14 days ER Stimulants GCN ADDERALL XR 5MG CAPSULE 17459 ADDERALL XR 10MG CAPSULE 14635 ADDERALL XR 15MG CAPSULE 17468 ADDERALL XR 20MG CAPSULE 14636 ADDERALL XR 25MG CAPSULE 17469 ADDERALL XR 30MG CAPSULE 14637 5MG EXTENDED- 17459 10MG EXTENDED- 14635 15MG EXTENDED- 17468 20MG EXTENDED- 14636 25MG EXTENDED- 17469 30MG EXTENDED- 14637 APTENSIO XR 10MG CAPSULE 97234 APTENSIO XR 15MG CAPSULE 97235 APTENSIO XR 20MG CAPSULE 97236 APTENSIO XR 30MG CAPSULE 97237 APTENSIO XR 40MG CAPSULE 97238 APTENSIO XR 50MG CAPSULE 97239 APTENSIO XR 60MG CAPSULE 97240 CONCERTA ER 18MG TABLET 12567 CONCERTA ER 27MG TABLET 17123 CONCERTA ER 36MG TABLET 12568 CONCERTA ER 54MG TABLET 12248 DAYTRANA 10MG/9HR PATCH 26801 DAYTRANA 15MG/9HR PATCH 26802 DAYTRANA 20MG/9HR PATCH 26803 DAYTRANA 30MG/9HR PATCH 26804 DEXEDRINE SPANSULE 5MG 19852 DEXEDRINE SPANSULE 10MG 19850 DEXEDRINE SPANSULE 15MG 19851 DEXTROAMPHETAMINE 5MG EXTENDED- 19852 DEXTROAMPHETAMINE 10MG EXTENDED- 19850 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 35
Label Name Step 4 (paid claim for another ER stimulant) Look back timeframe: 14 days ER Stimulants GCN DEXTROAMPHETAMINE 15MG EXTENDED- 19851 FOCALIN XR 5MG CAPSULE 24733 FOCALIN XR 10MG CAPSULE 24734 FOCALIN XR 15MG CAPSULE 97111 FOCALIN XR 20MG CAPSULE 24735 FOCALIN XR 25MG CAPSULE 30305 FOCALIN XR 30MG CAPSULE 28035 FOCALIN XR 35MG CAPSULE 30306 FOCALIN XR 40MG CAPSULE 28933 METADATE CD 10MG CAPSULE 20384 METADATE CD 20MG CAPSULE 20385 METADATE CD 30MG CAPSULE 20386 METADATE CD 40MG CAPSULE 26734 METADATE CD 50MG CAPSULE 26735 METADATE CD 60MG CAPSULE 26736 METADATE ER 10MG TABLET SA 93075 METADATE ER 20MG TABLET ER 16180 METHYLPHENIDATE 20MG EXTENDED- 20387 METHYLPHENIDATE 30MG EXTENDED- 20388 METHYLPHENIDATE 40MG EXTENDED- 20391 METHYLPHENIDATE CD 10MG EXTENDED- 20384 METHYLPHENIDATE CD 20MG EXTENDED- 20385 METHYLPHENIDATE CD 30MG EXTENDED- 20386 METHYLPHENIDATE CD 40MG EXTENDED- 26734 METHYLPHENIDATE CD 50MG EXTENDED- 26735 METHYLPHENIDATE CD 60MG EXTENDED- 26736 METHYLPHENIDATE 18MG EXTENDED- RELEASE TABLET 12567 METHYLPHENDIATE 20MG EXTENDED- RELEASE TABLET 16180 METHYLPHENIDATE 27MG EXTENDED- RELEASE TABLET 17123 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 36
Step 4 (paid claim for another ER stimulant) Look back timeframe: 14 days ER Stimulants Label Name GCN METHYLPHENIDATE 36MG EXTENDED- RELEASE TABLET 12568 METHYLPHENIDATE 54MG EXTENDED- RELEASE TABLET 12248 METHYLPHENIDATE 20MG SUSTAINED- RELEASE TABLET 16180 QUILLIVANT XR 25MG/5ML SUSP 33887 RITALIN LA 10MG CAPSULE 21763 RITALIN LA 20MG CAPSULE 20387 RITALIN LA 30MG CAPSULE 20388 RITALIN LA 40MG CAPSULE 20391 RITALIN SR 20MG TABLET 16180 VYVANSE 10MG CAPSULE 37674 VYVANSE 20MG CAPSULE 99366 VYVANSE 30MG CAPSULE 98071 VYVANSE 40MG CAPSULE 99367 VYVANSE 50MG CAPSULE 98072 VYVANSE 60MG CAPSULE 99368 VYVANSE 70MG CAPSULE 98073 Step 6 (diagnosis of ADD or ADHD) Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the ADD/ADHD Diagnoses table in the previous Supporting Tables section. Step 7 (diagnosis of narcolepsy) Required diagnosis: 1 Look back timeframe: 730 days For the list of diagnoses that pertain to this step, see the Narcolepsy Diagnoses table in the previous Supporting Tables section. March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 37
Step 8 (methylphenidate extended release tablets, methylphenidate sustained release tablets, or dextroamphetamine extended release capsules) Label Name GCN DEXEDRINE SPANSULE 5MG 19852 DEXEDRINE SPANSULE 10MG 19850 DEXEDRINE SPANSULE 15MG 19851 DEXTROAMPHETAMINE 5MG EXTENDED- DEXTROAMPHETAMINE 10MG EXTENDED- DEXTROAMPHETAMINE 15MG EXTENDED- 19852 19850 19851 METADATE ER 10MG TABLET SA 93075 METADATE ER 20MG TABLET ER 16180 METHYLPHENIDATE 10MG EXTENDED- RELEASE TABLET METHYLPHENIDATE 20MG EXTENDED- RELEASE TABLET 93075 16180 RITALIN SR 20MG TABLET 16180 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 38
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN INTUNIV ER 1MG TABLET 27576 INTUNIV ER 2MG TABLET 27578 INTUNIV ER 3MG TABLET 27579 INTUNIV ER 4MG TABLET 27582 STRATTERA 10MG CAPSULE 18776 STRATTERA 18MG CAPSULE 18777 STRATTERA 25MG CAPSULE 18778 STRATTERA 40MG CAPSULE 18779 STRATTERA 60MG CAPSULE 18781 STRATTERA 80MG CAPSULE 26538 STRATTERA 100MG CAPSULE 26539 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 39
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Clinical Edit Criteria Logic 1. Is the client less than (<) 6 years of age? [ ] Yes Deny [ ] No Go to #2 2. Is the request for greater than (>) 2 units per day? [] Yes Deny [] No Go to #3 3. Is the client greater than or equal to ( ) 19 years of age? [ ] Yes Go to #4 [ ] No Approve (365 days) 4. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [ ] Yes Approve (365 days) [ ] No Deny March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 40
Yes Yes Yes Yes Texas Prior Authorization Program Clinical Edits Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client less than 6 years of age? Is the request for greater than 2 units per day? Is the client greater than or equal to 19 years of age? Approve (365 days) Step 4 Deny Deny Does the client have a diagnosis of ADD/ADHD in the last 730 days? Deny Approve (365 days) March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 41
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Non-stimulant Formulations (Except Clonidine ER) Clinical Edit Criteria Supporting Tables Step 4 (diagnosis of ADD or ADHD) Look back timeframe: 730 days For the list of diagnoses that pertain to this step, please see the ADD/ADHD Diagnoses table in a previous Supporting Tables section. March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 42
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN CLONIDINE HCL ER 0.1-0.2MG DOSEPACK 33007 CLONIDINE HCL ER 0.1MG TABLET 29139 March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 43
Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Clinical Edit Criteria Logic 1. Is the client less than (<) 6 years of age? [ ] Yes Deny [ ] No - Go to #2 2. Is the request for greater than (>) 4 units per day? [ ] Yes Deny [ ] No Go to #3 3. Is the client greater than or equal to ( ) 19 years of age? [ ] Yes Go to #4 [ ] No Approve (365 days) 4. Does the client have a diagnosis of ADD/ADHD in the last 730 days? [ ] Yes Approve (365 days) [ ] No Deny March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 44
Yes Yes Yes Yes Texas Prior Authorization Program Clinical Edits Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) Clonidine ER Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client less than 6 years of age? Is the request for greater than 4 units per day? Is the client greater than or equal to 19 years of age? Approve (365 days) Deny Deny Step 4 Does the client have a diagnosis of ADD/ADHD in the last 730 days? Deny Approve (365 days) March 11, 2016 Copyright 2013-2016 Health Information Designs, LLC 45