Attention Deficit Disorder (ADD) / Attention Deficit ... ?· Attention Deficit Hyperactivity Disorder…

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<ul><li><p>August 15, 2017 Copyright 2013-2017 Health Information Designs, LLC 1 </p><p>Texas Prior Authorization Program </p><p>Clinical Criteria </p><p>Drug/Drug Class </p><p>Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD) </p><p>Medications </p><p>Clinical Criteria Information Included in this Document </p><p>IR Formulations </p><p> Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria </p><p> Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules </p><p> Logic diagram: a visual depiction of the clinical criteria logic </p><p> Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and </p><p>therapy codes) </p><p> References: clinical publications and sources relevant to this clinical </p><p>criteria </p><p>ER Formulations </p><p> Drugs requiring prior authorization: the list of drugs requiring </p><p>prior authorization for this clinical criteria </p><p> Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules </p><p> Logic diagram: a visual depiction of the clinical criteria logic </p><p> Supporting tables: a collection of information associated with the </p><p>steps within the criteria (diagnosis codes, procedure codes, and therapy codes) </p><p> References: clinical publications and sources relevant to this clinical criteria </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 2 </p><p>Non-stimulant Formulations (Except Clonidine ER) </p><p> Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria </p><p> Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules </p><p> Logic diagram: a visual depiction of the clinical criteria logic </p><p> Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and </p><p>therapy codes) </p><p> References: clinical publications and sources relevant to this clinical </p><p>criteria </p><p>Clonidine ER </p><p> Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria </p><p> Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules </p><p> Logic diagram: a visual depiction of the clinical criteria logic </p><p> Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and </p><p>therapy codes) </p><p> References: clinical publications and sources relevant to this clinical </p><p>criteria </p><p>Note: Click the hyperlink to navigate directly to that section. </p><p>Revision Notes </p><p>Added GCNs for Mydayis and Cotempla XR-ODAT to Drugs Requiring PA, </p><p>pages 27-30 </p><p>Updated criteria logic and logic diagram to include Mydayis, pages 31-34 </p><p>Updated Table 3, pages 36-37 </p><p>Updated Table 4, pages 38-41 </p><p>Updated references, pages 52-53</p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 3 </p><p>Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder </p><p>(ADHD) </p><p>IR Formulations Drugs Requiring Prior Authorization </p><p>Drug Requiring Prior Authorization </p><p>Label Name GCN </p><p>ADDERALL 10MG TABLET 56971 </p><p>ADDERALL 12.5MG TABLET 29008 </p><p>ADDERALL 15MG TABLET 29009 </p><p>ADDERALL 20MG TABLET 56973 </p><p>ADDERALL 30MG TABLET 56972 </p><p>ADDERALL 5MG TABLET 56970 </p><p>ADDERALL 7.5MG TABLET 29007 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 10MG TABLET </p><p>56971 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 12.5MG TABLET </p><p>29008 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 15MG TABLET </p><p>29009 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 20MG TABLET </p><p>56973 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 30MG TABLET </p><p>56972 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 5MG TABLET </p><p>56970 </p><p>AMPHETAMINE/DEXTROAMPHETAMINE SALTS 7.5MG TABLET </p><p>29007 </p><p>DESOXYN 5MG TABLET 19932 </p><p>DEXMETHYLPHENIDATE 10MG TABLET 14975 </p><p>DEXMETHYLPHENIDATE 2.5MG TABLET 14973 </p><p>DEXMETHYLPHENIDATE 5MG TABLET 14974 </p><p>DEXTROAMPHETAMINE 10MG TABLET 19880 </p><p>DEXTROAMPHETAMINE 5MG TABLET 19881 </p><p>DEXTROAMPHETAMINE 5MG/5ML SOLUTION 99801 </p><p>EVEKEO 10MG TABLET 19821 </p><p>EVEKEO 5MG TABLET 19822 </p><p>FOCALIN 10MG TABLET 14975 </p><p>FOCALIN 2.5MG TABLET 14973 </p><p>FOCALIN 5MG TABLET 14974 </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 4 </p><p>Drug Requiring Prior Authorization </p><p>Label Name GCN </p><p>METHAMPHETAMINE 5MG TABLET 19932 </p><p>METHYLIN 10MG CHEWABLE TABLET 22684 </p><p>METHYLIN 10MG/5ML SOLUTION 22686 </p><p>METHYLIN 2.5MG CHEWABLE TABLET 22682 </p><p>METHYLIN 5MG CHEWABLE TABLET 22683 </p><p>METHYLIN 5MG/5ML SOLUTION 22685 </p><p>METHYLPHENIDATE 10 MG CHEW TB 22684 </p><p>METHYLPHENIDATE 10MG TABLET 15911 </p><p>METHYLPHENIDATE 10MG/5ML SOL 22686 </p><p>METHYLPHENIDATE 2.5 MG CHEW TB 22682 </p><p>METHYLPHENIDATE 20MG TABLET 15920 </p><p>METHYLPHENIDATE 5 MG CHEW TB 22683 </p><p>METHYLPHENIDATE 5MG TABLET 15913 </p><p>METHYLPHENIDATE 5MG/5ML SOL 22685 </p><p>PROCENTRA 5MG/5ML SOLUTION 99801 </p><p>RITALIN 10MG TABLET 15911 </p><p>RITALIN 20MG TABLET 15920 </p><p>RITALIN 5MG TABLET 15913 </p><p>ZENZEDI 10MG TABLET 19880 </p><p>ZENZEDI 15MG TABLET 19885 </p><p>ZENZEDI 2.5MG TABLET 34734 </p><p>ZENZEDI 20MG TABLET 36463 </p><p>ZENZEDI 30MG TABLET 36464 </p><p>ZENZEDI 5MG TABLET 19881 </p><p>ZENZEDI 7.5MG TABLET 34735 </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 5 </p><p>Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder </p><p>(ADHD) </p><p>IR Formulations Clinical Criteria Logic </p><p>1. Is the client less than () the Texas Department of Family and Protective Services (DFPS) maximum recommended daily dose? [] Yes Deny [] No Go to #4 </p><p>4. Does the client have a paid claim for another IR stimulant in the past 14 </p><p>days? </p><p>[] Yes Deny [] No Go to #5 </p><p>5. Is the client less than (</p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 6 </p><p>Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder </p><p>(ADHD) </p><p>IR Formulations Clinical Criteria Logic Diagram </p><p>The IR Formulations Clinical Criteria Logic Diagram is shown on the following page. </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 7 </p><p>Step 1</p><p>Is the client less than 3 years of age?</p><p>Step 2</p><p>Does the client have a history of substance abuse in the last 365 </p><p>days?</p><p>Step 3</p><p>Is the request for greater than the TX </p><p>DFPS maximum daily dose?</p><p>Step 8</p><p>Does the client have a diagnosis of ADD/ADHD </p><p>in the last 730 days?</p><p>Step 7</p><p>Is the client greater than or equal to 19 years of </p><p>age?</p><p>Step 6Is the request for </p><p>amphetamine salts, dextroamphetamine, dexmethylphenidate, </p><p>methylphenidate, Procentra, or Zenzedi?</p><p>Step 9</p><p>Does the client have a diagnosis of narcolepsy </p><p>in the last 730 days?</p><p>Yes</p><p>Yes</p><p>Yes</p><p>Deny Deny</p><p>Approve (365 days)</p><p>Deny</p><p>DenyApprove </p><p>(365 days)</p><p>Deny</p><p>Approve(365 days)</p><p>Step 10</p><p>Is the request for dexmethylphenidate or </p><p>methamphetamine?</p><p>Step 5</p><p>Is the client less than 6 years of age?</p><p>No</p><p>No</p><p>Step 4</p><p>Does the client have a paid claim for another IR stimulant in the past </p><p>14 days?</p><p>Deny</p><p>No</p><p>Yes</p><p>No</p><p>Yes</p><p>Yes</p><p>Yes No</p><p>No</p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 8 </p><p>Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder </p><p>(ADHD) </p><p>IR Formulations Clinical Criteria Supporting Tables </p><p>Step 2 (history of substance abuse) </p><p>Required quantity: 1 </p><p>Look back timeframe: 365 days </p><p>History of Substance Abuse Diagnoses </p><p>ICD-9 Code Description </p><p>30400 OPIOID DEPENDENCE-UNSPEC </p><p>30401 OPIOID DEPENDENCE-CONTIN </p><p>30402 OPIOID DEPENDENCE-EPISOD </p><p>30403 OPIOID DEPENDENCE-REMISS </p><p>30410 SEDATIVE,HYPNOTIC OR ANXIOLYTIC DEPENDENCE UNSPECIFIED </p><p>30411 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, CONTINUOUS </p><p>30412 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC </p><p>30413 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION </p><p>30420 COCAINE DEPEND-UNSPEC </p><p>30421 COCAINE DEPEND-CONTIN </p><p>30422 COCAINE DEPEND-EPISODIC </p><p>30423 COCAINE DEPEND-REMISS </p><p>30430 CANNABIS DEPEND-UNSPEC </p><p>30431 CANNABIS DEPEND-CONTIN </p><p>30432 CANNABIS DEPEND-EPISODIC </p><p>30433 CANNABIS DEPEND-REMISS </p><p>30440 AMPHETAMIN DEPEND-UNSPEC </p><p>30441 AMPHETAMIN DEPEND-CONTIN </p><p>30442 AMPHETAMIN DEPEND-EPISOD </p><p>30443 AMPHETAMIN DEPEND-REMISS </p><p>30450 HALLUCINOGEN DEP-UNSPEC </p><p>30451 HALLUCINOGEN DEP-CONTIN </p><p>30452 HALLUCINOGEN DEP-EPISOD </p><p>30453 HALLUCINOGEN DEP-REMISS </p><p>30460 DRUG DEPEND NEC-UNSPEC </p><p>30461 DRUG DEPEND NEC-CONTIN </p><p>30462 DRUG DEPEND NEC-EPISODIC </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 9 </p><p>Step 2 (history of substance abuse) </p><p>Required quantity: 1 </p><p>Look back timeframe: 365 days </p><p>History of Substance Abuse Diagnoses </p><p>30463 DRUG DEPEND NEC-IN REM </p><p>30470 OPIOID/OTHER DEP-UNSPEC </p><p>30471 OPIOID/OTHER DEP-CONTIN </p><p>30472 OPIOID/OTHER DEP-EPISOD </p><p>30473 OPIOID/OTHER DEP-REMISS </p><p>30480 COMB DRUG DEP NEC-UNSPEC </p><p>30481 COMB DRUG DEP NEC-CONTIN </p><p>30482 COMB DRUG DEP NEC-EPISOD </p><p>30483 COMB DRUG DEP NEC-REMISS </p><p>30490 DRUG DEPEND NOS-UNSPEC </p><p>30491 DRUG DEPEND NOS-CONTIN </p><p>30492 DRUG DEPEND NOS-EPISODIC </p><p>30493 DRUG DEPEND NOS-REMISS </p><p>30500 ALCOHOL ABUSE-UNSPEC </p><p>30501 ALCOHOL ABUSE-CONTINUOUS </p><p>30502 ALCOHOL ABUSE-EPISODIC </p><p>30503 ALCOHOL ABUSE-IN REMISS </p><p>30520 CANNABIS ABUSE-UNSPEC </p><p>30521 CANNABIS ABUSE-CONTIN </p><p>30522 CANNABIS ABUSE-EPISODIC </p><p>30523 CANNABIS ABUSE-IN REMISS </p><p>30530 HALLUCINOG ABUSE-UNSPEC </p><p>30531 HALLUCINOG ABUSE-CONTIN </p><p>30532 HALLUCINOG ABUSE-EPISOD </p><p>30533 HALLUCINOG ABUSE-REMISS </p><p>30540 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED </p><p>30541 SEDATIVE, HYPNOTIC OR ANXIOLYTIC, ABUSE, CONTINUOUS </p><p>30542 SEDATIVE, HYPNOTIC, OR ANXIOLYTIC ABUSE, EPISODIC </p><p>30543 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION </p><p>30550 OPIOID ABUSE-UNSPEC </p><p>30551 OPIOID ABUSE-CONTINUOUS </p><p>30552 OPIOID ABUSE-EPISODIC </p><p>30553 OPIOID ABUSE-IN REMISS </p><p>30560 COCAINE ABUSE-UNSPEC </p><p>30561 COCAINE ABUSE-CONTINUOUS </p><p>30562 COCAINE ABUSE-EPISODIC </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 10 </p><p>Step 2 (history of substance abuse) </p><p>Required quantity: 1 </p><p>Look back timeframe: 365 days </p><p>History of Substance Abuse Diagnoses </p><p>30563 COCAINE ABUSE-IN REMISS </p><p>30570 AMPHETAMINE ABUSE-UNSPEC </p><p>30571 AMPHETAMINE ABUSE-CONTIN </p><p>30572 AMPHETAMINE ABUSE-EPISOD </p><p>30573 AMPHETAMINE ABUSE-REMISS </p><p>30590 DRUG ABUSE NEC-UNSPEC </p><p>30591 DRUG ABUSE NEC-CONTIN </p><p>30592 DRUG ABUSE NEC-EPISODIC </p><p>30593 DRUG ABUSE NEC-IN REMISS </p><p>ICD-10 Code Description </p><p>F1010 ALCOHOL ABUSE UNCOMPLICATED </p><p>F10120 ALCOHOL ABUSE WITH INTOXICATION UNCOMPLICATED </p><p>F10121 ALCOHOL ABUSE WITH INTOXICATION DELIRIUM </p><p>F10129 ALCOHOL ABUSE WITH INTOXICATION UNSPECIFIED </p><p>F1014 ALCOHOL ABUSE WITH ALCOHOL-INDUCED MOOD DISORDER </p><p>F10150 ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC DISORDER </p><p>WITH DELUSIONS </p><p>F10151 ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC DISORDER </p><p>WITH HALLUCINATIONS </p><p>F10159 ALCOHOL ABUSE WITH ALCOHOL-INDUCED PSYCHOTIC DISORDER </p><p>UNSPECIFIED </p><p>F10180 ALCOHOL ABUSE WITH ALCOHOL-INDUCED ANXIETY DISORDER </p><p>F10181 ALCOHOL ABUSE WITH ALCOHOL-INDUCED SEXUAL DYSFUNCTION </p><p>F10182 ALCOHOL ABUSE WITH ALCOHOL-INDUCED SLEEP DISORDER </p><p>F10188 ALCOHOL ABUSE WITH OTHER ALCOHOL-INDUCED DISORDER </p><p>F1019 ALCOHOL ABUSE WITH UNSPECIFIED ALCOHOL-INDUCED DISORDER </p><p>F1020 ALCOHOL DEPENDENCE UNCOMPLICATED </p><p>F10220 ALCOHOL DEPENDENCE WITH INTOXICATION UNCOMPLICATED </p><p>F10221 ALCOHOL DEPENDENCE WITH INTOXICATION DELIRIUM </p><p>F10229 ALCOHOL DEPENDENCE WITH INTOXICATION UNSPECIFIED </p><p>F10230 ALCOHOL DEPENDENCE WITH WITHDRAWAL UNCOMPLICATED </p><p>F10231 ALCOHOL DEPENDENCE WITH WITHDRAWAL DELIRIUM </p><p>F10232 ALCOHOL DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE </p><p>F10239 ALCOHOL DEPENDENCE WITH WITHDRAWAL UNSPECIFIED </p><p>F1024 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED MOOD DISORDER </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 11 </p><p>Step 2 (history of substance abuse) </p><p>Required quantity: 1 </p><p>Look back timeframe: 365 days </p><p>History of Substance Abuse Diagnoses </p><p>F10250 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS </p><p>F10251 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS </p><p>F10259 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PSYCHOTIC DISORDER UNSPECIFIED </p><p>F1026 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDER </p><p>F1027 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED PERSISTING DEMENTIA </p><p>F10280 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED ANXIETY </p><p>DISORDER </p><p>F10281 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED SEXUAL </p><p>DYSFUNCTION </p><p>F10282 ALCOHOL DEPENDENCE WITH ALCOHOL-INDUCED SLEEP DISORDER </p><p>F10288 ALCOHOL DEPENDENCE WITH OTHER ALCOHOL-INDUCED DISORDER </p><p>F1029 ALCOHOL DEPENDENCE WITH UNSPECIFIED ALCOHOL-INDUCED </p><p>DISORDER </p><p>F1110 OPIOID ABUSE UNCOMPLICATED </p><p>F11120 OPIOID ABUSE WITH INTOXICATION UNCOMPLICATED </p><p>F11121 OPIOID ABUSE WITH INTOXICATION DELIRIUM </p><p>F11122 OPIOID ABUSE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE </p><p>F11129 OPIOID ABUSE WITH INTOXICATION UNSPECIFIED </p><p>F1114 OPIOID ABUSE WITH OPIOID-INDUCED MOOD DISORDER </p><p>F11150 OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS </p><p>F11151 OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS </p><p>F11159 OPIOID ABUSE WITH OPIOID-INDUCED PSYCHOTIC DISORDER </p><p>UNSPECIFIED </p><p>F11181 OPIOID ABUSE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION </p><p>F11182 OPIOID ABUSE WITH OPIOID-INDUCED SLEEP DISORDER </p><p>F11188 OPIOID ABUSE WITH OTHER OPIOID-INDUCED DISORDER </p><p>F1119 OPIOID ABUSE WITH UNSPECIFIED OPIOID-INDUCED DISORDER </p><p>F1120 OPIOID DEPENDENCE, UNCOMPLICATED </p><p>F1121 OPIOID DEPENDENCE, IN REMISSION </p><p>F11220 OPIOID DEPENDENCE WITH INTOXICATION UNCOMPLICATED </p><p>F11221 OPIOID DEPENDENCE WITH INTOXICATION DELIRIUM </p></li><li><p>Texas Prior Authorization Program Clinical Criteria ADD/ADHD Medications </p><p>August 23, 2017 Copyright 2013-2017 Health Information Designs, LLC 12 </p><p>Step 2 (history of substance abuse) </p><p>Required quantity: 1 </p><p>Look back timeframe: 365 days </p><p>History of Substance Abuse Diagnoses </p><p>F11222 OPIOID DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE </p><p>F11229 OPIOID DEPENDENCE WITH INTOXICATION UNSPECIFIED </p><p>F1123 OPIOID DEPENDENCE WITH WITHDRAWAL </p><p>F1124 OPIOID DEPENDENCE WITH OPIOID-INDUCED MOOD DISORDER </p><p>F11250 OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC </p><p>DISORDER WITH DELUSIONS </p><p>F11251 OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC </p><p>DISORDER WITH HALLUCINATIONS </p><p>F11259 OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER UNSPECIFIED </p><p>F11281 OPIOID DEPENDENCE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION </p><p>F11282 OPIOID DEPENDENCE WITH OPIOID-INDUCED SLEEP DISORDER </p><p>F11288 OPIOID DEPENDENC...</p></li></ul>

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