Texas Prior Authorization Program Clinical Criteria Drug/Drug
Texas Prior Authorization ProgramClinical CriteriaDrug/Drug ClassDextromethorphan OverutilizationClinical Criteria Information Included in this Document Drugs Requiring PA: the list of drugs requiring prior authorization forthis clinical criteria Drug Classification: classification of each drug requiring PA Age and Dosing Limits: the maximum dose/day based on client’s ageand drug classificationNote: Click the hyperlink to navigate directly to that information.Revision NotesAdded GCN for Polytussin DM to tableDecember 30, 2019Copyright 2019 Health Information Designs, LLC1
Texas Prior Authorization Program Clinical CriteriaDextromethorphan OverutilizationDextromethorphan OverutilizationDrug Classification1. Obtain the client’s age. (Make a note of it for future reference.)2. In the following table, locate the Classification associated with the incomingrequest’s label name. (Make a note of it for future reference.)3. Once you have located the classification, proceed to step 4 on the Age andDosing Limits page.The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn thecurrent formulary coverage, visit TxVendorDrug.com/formulary/formulary-search.Drugs Requiring PALabel NameGCNClassificationALA-HIST DM LIQUIDALAHIST DM LIQUIDAP-HIST DM LIQUIDALLFEN DM TABLETBROMFED DM COUGH SYRUPBROMPHENIR-PSEUDOEPHEN-DM SYRBROTAPP DM LIQUIDCHILD DELSYM COUGH CHEST DM LQCHILDREN COLD & COUGH DM ELIXICHILDREN'S MUCINEX COUGH LIQCHILD MUCINEX CONGEST-COUGH LIQCHILD MUCINEX MULTI-SYMPTOM LIQCOUGH DM ER 30MG/5ML SUSPENSIONDAYTIME COLD-FLU RELIEFDECONEX DMX TABLET 17.5-400-10MG TABDECONEX DMX TABLET 17.5-385-10MG TABDELSYM 30 MG/5 ML SUSPENSIONDELSYM COUGH CHEST CNGST DM LQDEXTROMETHORPHAN ER 30MG/5MLDIMAPHEN DM ELIXIRED-A-HIST DM LIQUIDED-A-HIST DM TABLETENDACOF-DM LIQUIDEXTRA ACTION COUGH SYRUPFLU-SEVERE COLD-COUGH DAY PACKETHISTEX-DM r 30, 2019Copyright 2019 Health Information Designs, LLCNNNAAQQUUUUUUIVAAAAIUIUNAAUQZI2
Texas Prior Authorization Program Clinical CriteriaDextromethorphan OverutilizationDrugs Requiring PALabel NameGCNClassificationIOPHEN DM-NR LIQUIDKIDKARE COUGH & COLD LIQUIDLOHIST-DM SYRUPLORTUSS DM LIQUIDM-END DMX LIQUIDM-HIST DM LIQUIDMAXIPHEN DM TABLETMUCINEX COUGH MINI-MELT PACKMUCINEX DM ER 600-30 MG TABLETMUCINEX DM ER 1,200-60 MG TABMUCINEX FAST-MAX CONGEST-COUGHMUCINEX FAST-MAX DM MAX LIQUIDNOHIST-DM LIQUIDPEDIATRIC COUGH-COLD LIQUIDPOLY-HIST DM LIQUIDPOLYTUSSIN DM SYRUPPOLY-VENT DM TABLETPROMETHAZINE-DM SYRUPRESCON-DM LIQUIDROBAFEN CF LIQUIDROBAFEN-DM SYRUPROBAFEN DM COUGH LIQUIDROBAFEN COUGH 15 MG LIQUIDGELROBAFEN DM CGH-CHEST CONG SYRUPRYNEX DM LIQUIDSILTUSSIN DM COUGH SYRUPSILTUSSIN DM DAS LIQUIDSM TUSSIN DM LIQUIDSM TUSSIN DM SYRUPTUSSIN DM CLEAR LIQUIDTUSSIN DM LIQUIDTUSSIN DM SYRUPVANACOF DM LIQUIDVANATAB DM cember 30, 2019Copyright 2019 Health Information Designs, LLCQSQOQNYFFYWUUNSOQYNOQQQBBQUQQQQQQQTDD3
Texas Prior Authorization Program Clinical CriteriaDextromethorphan OverutilizationDextromethorphan OverutilizationAge and Dosing LimitsUse the classification and client’s age to locate the dosing limit in the MaximumDose/Day column.Age and Dosing LimitsClassificationAgeMaximum Dose/Day6-11 years10 ml12 years and older20 ml6-11 years15 ml12 years and older30 ml6-11 years20 ml12 years and older40 mlAppendix Q6-11 years12 years and older30 ml60 mlAppendix S6-11 years12 years and older40 ml80 mlAppendix T6-11 years12 years and older45 ml90 ml6-11 years60 ml12 years and older120 mlAppendix V6-11 years12 years and older90 ml180 mlAppendix W12 years and older2 units6-11 years2 units12 years and older4 units12 years and older5 units6-11 years3 units12 years and older6 unitsAppendix BB12 years and older8 unitsAppendix DD6-11 years12 years and older6 units12 unitsAppendix FF6-11 years12 years and older12 units24 unitsAppendix IAppendix NAppendix OAppendix UAppendix YAppendix ZAppendix AADecember 30, 2019Copyright 2019 Health Information Designs, LLC4
Texas Prior Authorization Program Clinical CriteriaDextromethorphan OverutilizationPublication HistoryThe Publication History records the publication iterations and revisions to thisdocument. Notes for the most current revision are also provided in theRevision Notes on the first page of this document.PublicationDateNotes07/18/2012Initial publication and posting to website02/16/2016Updated GCNS and dosing guidelines01/20/2017Added GCNs for Alahist DM liquid, Ed-A-Hist DM tablet, GuaifenesinDM ER 1,200-60 mg tablets, Robafen Cough 15 mg liquidgel andRobafen DM cough-chest congestion syrup02/07/2018Annual review by staffAdded GCNs for M-Hist DM liquid and Vanatab DM caplet, page 3Updated GCNs and dosing guidelines07/17/2018Updated age and dosing table, page 403/27/2019Updated to include formulary statement (The listed GCNS may notbe an indication of TX Medicaid Formulary coverage. To learn thecurrent formulary coverage, visitTxVendorDrug.com/formulary/formulary-search.) on each ‘DrugRequiring PA’ table09/26/2019Added GCN for Deconex DMX to drug table11/20/2019Added GCNs for Daytime Cold-Flu Relief and Flu-Severe Cold-CoughDay packet to drug table12/30/2019Added GCN for Polytussin DM syrup to drug tableDecember 30, 2019Copyright 2019 Health Information Designs, LLC5
BROMPHENIR-PSEUDOEPHEN-DM SYR 96136 Appendix Q BROTAPP DM LIQUID 12934 Appendix U CHILD DELSYM COUGH CHEST DM LQ 53497 Appendix U CHILDREN COLD & COUGH DM ELIXI 26808 Appendix U CHILDREN'S MUCINEX COUGH LIQ 53497 Appendix U CHILD MUCINEX CONGEST-COUGH LIQ 28875 Appendix U CHILD MUCINEX MULTI
Forteo (Teriparatide) Clinical Criteria Information Included in this Document Forteo (Teriparatide) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior
4 For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient. Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required.
Gold-Carding Gold-carding: A process that exempts providers with a record of consistent adherence to prior authorization criteria from prior authorization submission requirements Promotes more timely access to care by eliminating unnecessary obstacles between patients and treatments. Allows health plans to focus prior authorization on
Jane Doe with authorization code 654321 and authorization level 2 . Joe user with authorization code 999999 and authorization level 1 . Step 2.-Configuring Forced Authorization Codes . Go to the administration page of Cisco Unified Comm unications Manager, select Call Routing TAB, then select Force Authorization Codes as shown in the image s below.
Authorization for Services to Children Enrolled in CMS Safety Net Program 5 Section 2.0. Process for Requesting Prior Authorization 7 2.0.1. Submitting Prior Authorization Requests 7 2.0.2. Response Time for Prior Authorization Requests 7 2.0.3. Appeal Process for Denied, Reduced, Suspended, or Termination of Services 8 .
C. Clinical Review Process Prior authorization personnel will review the request for prior authorization and apply the clinical guidelines in Section B.
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