Approval criteria - Arkansas Medicaid by wuxiangyu

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									Arkansas Medicaid Prescription Drug Program
    Preferred Drug List Criteria Overview




           Revised November 5, 2009




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  Arkansas Medicaid Prescription Drug Program
      Preferred Drug List Criteria Overview
Class                                                         Page
Second Generation Antihistamines                                       3
Angiotensin-Converting Enzyme Inhibitors                               5
Beta Adrenergic Blocking Agents                                        6
HMG-CoA Reductase Inhibitors                                           7
Long Acting Opioids                                                    8
Proton Pump Inhibitors                                                 9
Serotonin 5-HT 1 Receptor Agonists                                     10
Angiotensin II Receptor Antagonists                                    11
Skeletal Muscle Relaxants                                              12
Targeted Immune Modulators                                             13
Non-Benzodiazepine Sedative Hypnotics                                  17
5-HT3 or NK1 Receptor Antagonists                                      18
Overactive Bladder Agents                                              19
Second Generation Antidepressant                                       21
Nonsteroidal Antiinflammatories                                        23
Attenion Deficit (Hyperactivity) Disorder Drugs                        25
Neuropathic Pain Agents                                                26
Hormone Replacement Agents                                             28
Short Acting Bronchodilators – Quick Relief Asthma Medication          29
Inhaled Corticosteroids – Controller Asthma Medication                 30
Long Acting Beta2 Agonists – Controller Asthma Medication              31
Inhaled Beta2 Agonists/Corticosteroid – Controller Asthma Medication   32
Leukotriene Receptor Antagonists                                       33

Appendix A – Congestive Heart Failure
Appendix B – Malignant Cancer Diagnoses
Appendix C – Antineoplastics to Infer Malignant Cancer
Appendix D – Skeletal Muscle Relaxants Diagnoses
Appendix E – Nil per os (NPO)
Appendix F – Targeted Immune Modulator Diagnoses
Appendix G – Respiratory Insufficiency Diagnoses
Appendix H – Spinal Bifida Diagnoses
Appendix I – Minimum and Maximum Dose for Second Generation
Antidepressants
Appendix J – Selective Serotonin Reuptake Inhibitors (Combinations)
Appendix K – Chronic Obstruction Pulmonary Disease Diagnoses
Appendix L – Non-Preferred Antiepileptic Agents in Neuropathic Pain Agent
Class
Appendix M – Approved Diagnoses for Non-Preferred Antiepileptic Agents
in Neuropathic Pain Agent Class
Appendix N – Postherpetic Neuralgia Diagnosis
Appendix O – Antivirals
Appendix P -- Tracheostomy
Appendix Q – Opioid Dependence Diagnoses


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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview
Prescribers may request an override for Non-preferred drugs by calling the
UAMS College of Pharmacy Evidence-Based Prescription Drug Program
Help Desk at: Toll Free 1-866-250-2518 or Local 501-526-4200

Please refer to the Arkansas Medicaid Webpage at
http://www.medicaid.state.ar.us/ for the complete list of drugs.

Other claim edits for age, gender, quantity, dose, and/or cumulative quantity
may apply.




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Second Generation Antihistamines
Preferred agents:
      Loratidine (Claritin)

Non-preferred agents with criteria:
      Cetirizine
          o Cetirizine (Zyrtec)
          o Cetirizine w/pseudoephedrine (Zyrtec-D)
      Desloratadine
          o Desloratadine (Clarinex)
          o Desloratadine w/pseudoephedrine (Clarinex-D)
      Fexofenadine
          o Fexofenadine (Allegra)
          o Fexofenadine w/pseudoephedrine (Allegra-D)
      Levocetirizine (Xyzal)
      Loratadine w/pseudoephedrine (Claritin-D)

Approval criteria:
      Cetirizine liquid and Desloratidine liquid
          o Patient is greater than 6 months of age but less than 24 months of
               age.

      All non-preferred drugs
           o > 4 claims for the drug, strength, and dosage form of any non-
              preferred drug in the last 6 months:




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Angiotensin-Converting Enzyme Inhibitors
Preferred agents:
      Benazepril (Lotensin)
      Benazepril/Amlodipine besylate (Lotrel)
      Lisinopril (Prinivil)
      Captopril (Capoten)
      Ramipril Capsules (Altace Capsules)

Non-preferred agents with criteria:

      Enalapril maleate (Vasotec)

Non-preferred agents:
      Enalapril Maleate/Felodipine (Lexxel)
      Fosinopril (Monopril)
      Moexipril (Univasc)
      Perindopril erbumine (Aceon)
      Quinapril (Accupril)
      Ramipril Tablets (Altace Tablets)
      Trandopril (Mavik)
      Trandopril/Verapamil HCL (Tarka)

Approval Criteria for Non-preferred Agents with criteria:
      Enalapril
         o Patient is less than 18 years of age




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Beta Adrenergic Blocking Agents
Preferred agents:
      Atenolol (Tenormin)
      Metoprolol tartrate (Lopressor)
      Propranolol immediate release (Inderal)

Preferred agents with criteria:
      Bisoprolol fumarate (Zebeta)
      Carvedilol tablet (Coreg)
      Metoprolol (Toprol XL)

Non-preferred agents:

      Acebutolol (Sectral)
      Betaxolol HCl (Kerlone)
      Carteolol HCl (Cartrol)
      Carvedilol controlled release capsule (Coreg CR)
      Labetalol HCl (Normodyne)
      Nadolol (Corgard)
      Nebivolol (Bystolic)
      Penbutolol sulfate (Levatol)
      Pindolol (Visken)
      Propranolol HCl sustained release capsule (Inderal LA)
      Timolol maleate (Blocadren)

Approval Criteria:
      Bisoprolol fumarate, Carvedilol tablet and Toprol XL
          o Congested heart failure (Appendix A)




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 HMG-CoA Reductase Inhibitors
Preferred agents:
      Pravastatin (Pravachol)
      Simvastatin (Zocor)

Non-preferred agents with criteria:
      Atorvastatin 80mg (Lipitor)

Non-preferred agents:

      Atorvastatin (Lipitor)
      Fluvastatin (Lescol)
      Lovastatin (Mevacor)
      Lovastatin/Niacin extended release (Advicor)
      Pravastatin/Aspirin (Pravigard PAC)
      Rosuvastatin (Crestor)
      Simvastatin/Ezetimibe (Vytorin)
      Simvastatin/Niacin (Simcor)

Approval criteria:
      Atorvastatin 80mg
          o 4 or more claims for atorvastatin 80mg within past 6 months




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     Arkansas Medicaid Prescription Drug Program
         Preferred Drug List Criteria Overview

 Long Acting Opioids
Preferred agents with criteria:
        Methadone (Dolophine)
        Morphine sulfate long acting tablet (MS Contin, Oramorph)
        Oxymorphone long acting tablet (Opana ER)

Non-preferred agents with criteria:

        Fentanyl patch (Duragesic)
        Morphine Sulfate long acting capsule (Avinza, Kadian)
        Morphine Sulfate/Naltrexone (Embeda)
        Oxycodone long acting tablet (Oxycontin)

Approval criteria for preferred agents:
        <= 1 Therapeutic duplication in drug history between long-acting narcotics
         with ≤75% overlap of the last fill in the last 93 days

Approval criteria for non-preferred agents:
        Fentanyl patch
            o NPO (Appendix E), OR
            o Currently LTC, OR
            o Cancer with malignancies (Appendix B) or antineoplastic drug
               history (Appendix C) in past 12 months
            AND
            o <=1 Therapeutic duplication in drug history between long-acting
               narcotics with ≤75% overlap of the last fill in the last 93 days

        Morphine sulfate long acting capsule or oxycodone long acting tablet
           o Currently LTC, OR
           o Cancer with malignancies (Appendix B) or antineoplastic drug
               history (Appendix C) in past 12 months
           AND
           o <=1 Therapeutic duplication in drug history between long-acting
               narcotics with ≤75% overlap of the last fill in the last 93 days

Denial criteria for all agents:
        Paid claim for Suboxone or Subutex in the past 60 days


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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Proton Pump Inhibitors
Preferred agents:
      Esomeprazole (Nexium)
      Omeprazole 20mg capsule (Rx Prilosec)

Non-preferred agents with criteria:
      Lansoprazole capsule (Prevacid Capsules)
      Lansoprazole solutab (Prevacid Solutabs)

Non-preferred agents:

      Dexlansoprazole (Kapidex)
      Esomeprazole packets (Nexium Packets)
      Lansoprazole suspension (Prevacid Suspension)
      Omeprazole 10mg capsule; 40mg capsule (Rx Prilosec)
      Omeprazole 20mg tablet (OTC Prilosec)
      Omeprazole suspension (Prilosec)
      Omeprazole sodium bicarbonate (Zegerid)
      Pantoprazole (Protonix)
      Rabeprazole (Aciphex)

Approval criteria:
      Prevacid Capsules
          o Less than 1 years of age

      Prevacid Solutabs
          o Less than 7 years of age
          o 7 years of age and older with documented history of NPO
             (Appendix E) within past 365 days




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Serotonin 5-HT 1 Receptor Agonists
Preferred agents with criteria:
      Rizatriptan (Maxalt)
      Sumatriptan 5 mg nasal spray (Imitrex)
      Sumatriptan 20 mg nasal spray (Imitrex)
      Sumatriptan 4 mg/0.5 ml kit refill (Imitrex)
      Sumatriptan 6 mg/0.5 ml kit refill (Imitrex)
      Sumatriptan 6 mg/0.5 ml kit syringe (Imitrex)
      Sumatriptan 6 mg/0.5 ml vial (Imitrex)
      Sumatriptan 25 mg tablet (Imitrex)
      Sumatriptan 100 mg tablet (Imitrex)
      Sumatriptan/Naproxen (Treximet)

Non-preferred agents:

      Almotriptan malate (Axert)
      Eletriptan HBr (Relpax)
      Frovatriptan succinate (Frova)
      Naratriptan HCl (Amerge)
      Sumatriptan 4 mg/0.5 ml vial
      Zolmitriptan (Zomig)

Approval criteria:
      Preferred Injection
          o Any serotonin 5HT 1 receptor antagonist within past 365 days

Denial criteria:
      Therapeutic Duplication of any Serotonin 5-HT 1 Receptor Agonist




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview


 Angiotensin II Receptor Antagonists
Preferred agents:
      Losartan(Cozaar)
      Losartan/HCTZ (Hyzaar)
      Olmesartan (Benicar)
      Olmesartan/Amlodipine (Azor)
      Olmesartan/HCTZ (Benicar HCT)
      Valsartan(Diovan)
      Valsartan/Amlodipine (Exforge)
      Valsartan/HCTZ (Diovan HCT)

Non-preferred agents with criteria:
      Candesartan (Atacand)

Non-preferred agents:

      Candesartan/HCTZ (Atacand HCT)
      Eprosartan (Teveten)
      Eprosartan/HCTZ (Teveten HCT)
      Irbesartan (Avapro)
      Irbesartan/HCTZ (Avalide)
      Telmisartan (Micardis)
      Telmisartan/Amlodipine (Twynsta)
      Telmisartan/HCTZ (Micardis HCT)
      Valsartan/Aliskiren (Valturna)
      Valsartan/Amlodipine/HCTZ (Exforge HCT)


Approval criteria:
      Candesartan
           o Congested heart failure (Appendix A)




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Skeletal Muscle Relaxants
Preferred agents:
      Chlorzoxazone (Parafon)
      Cyclobenzaprine 10mg tablet (Flexeril)
      Methocarbamol tablet (Robaxin)

Preferred agents with criteria:
      Baclofen tablet (Lioresal)
      Tizanidine tablet (Zanaflex)

Non-preferred agents:

      Carisoprodol (Soma)
      Carisoprodol/Aspirin (Soma Compound)
      Carisoprodol/Aspirin/Codeine (Soma Compound w/ Codeine)
      Cyclobenzaprine 5mg and 7.5mg tablet (Flexeril, Fexmid)
      Dantrolene (Dantrium)
      Metaxalone (Skelaxin)
      Orphenadrine citrate (Norflex)
      Orphenadrine/Aspirin/Caffeine (Norgesic)
      Tizanidine capsule (Zanaflex)

Approval criteria:
      Baclofen and Tizanidine
          One of the following diagnoses (Appendix D)
          o Cerebral Palsy
          o Cerebrovascular Accident
          o Multiple Sclerosis
          o Spinal Cord Injury
          o Traumatic Brain Injury
          o Other spastic conditions




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   Arkansas Medicaid Prescription Drug Program
       Preferred Drug List Criteria Overview

 Targeted Immunemodulators
Preferred agents with criteria:
      Adalimumab (Humira)
      Efalizumab (Raptiva)
      Etanercept (Enbrel)

Non-preferred agents:
      Anakinra (Kineret)
      Certolizumab (Cimzia)
      Golimumab (Simponi)
      Infliximab (Remicade)
      Ustekinumab (Stelara)

Approval criteria:
      Approval criteria for Enbrel
       Must meet one of the following 6 criteria:
           o Criteria 1:
               Submitted diagnosis of psoriasis (Appendix F) in the past 2
                  years, AND
               Age >17, AND
               Paid Drug claim for etanercept (Enbrel) in past 45 days
                  (Signifying Above Criteria Previously Met)
           o Criteria 2:
               Submitted diagnosis of psoriasis (Appendix F) in the past 2
                  years, AND
               Age >17, AND
               During days 180 to 395 days ago, a total of >180 days of
                  topical drug therapy with: anthralin, calcipotriene,
                  corticosteroids, or tazarotene in past 395 days, AND
               During days 1-210 ago, a total of >180 days of systemic drug
                  therapy with: cyclosporine, methotrexate, or acitretin, AND
               Topical drug therapy trial occurred before systemic drug
                  therapy
           o Criteria 3:
               Submitted ICD-9 diagnosis of ankylosing spondylosis
                  (Appendix F) in past 2 years
           o Criteria 4:
               Submitted ICD-9 diagnosis of rheumatoid arthritis (Appendix
                  F) or psoriatic arthropathy (Appendix F) in past 2 years, AND


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Arkansas Medicaid Prescription Drug Program
    Preferred Drug List Criteria Overview
             >180 days of drug therapy in the past 365 days with any of the
              following: gold compounds, hydroxychloroquine,
              penicillamine, methotrexate, azathioprine, sulfasalazine, or
              leflunomide
        o Criteria 5:
           Submitted ICD-9 diagnosis of rheumatoid arthritis (Appendix
              F) or psoriatic arthropathy (Appendix F) in past 2 years, AND
           Paid Drug claim for etanercept (Enbrel) in past 45 days
              (Signifying Above Criteria Previously Met)
        o Criteria 6:
           Submitted ICD-9 diagnosis of rheumatoid arthritis (Appendix
              F) in past 2 years, AND
           Age <18

   Approval criteria for Humira
    Must meet one of the following 8 criteria:
        o Criteria 1:
            Submitted ICD-9 diagnosis of ankylosing spondylosis
               (Appendix F) in past 2 years
        o Criteria 2:
            Submitted diagnosis for rheumatoid arthritis (Appendix F) or
               psoriatic arthropathy (Appendix F) in the past 2 years, AND
            One of the following :
                   >6 claims for any of the following in the past 365 days:
                      gold compounds, hydroxychloroquine, penicillamine,
                      methotrexate, azathioprine, sulfasalazine, or
                      leflunomide, OR
                   Paid Drug claim for adalimumab (Humira) in the past 45
                      days (Signifying Above Criteria Previously Met)
        o Criteria 3:
           Age >18 years, AND
           Submitted ICD-9 diagnosis code for Crohn’s disease
              (Appendix F) or regional enteritis (Appendix F) in past 2 Years,
              AND
           Submitted ICD-9 diagnosis code for fistula (Appendix F) in
              past 2 Years
        o Criteria 4:
           Age >18 years, AND
           Submitted ICD-9 diagnosis code for Crohn’s disease
              (Appendix F) or regional enteritis (Appendix F) in past 2 Years,
              AND
           >180 days drug therapy of one of the following regimens in the
              past 365 days:
                   concurrent systemic glucocorticoid AND mesalamine
                      therapy, OR
                   mercaptopurine, OR
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    Preferred Drug List Criteria Overview
                   azathioprine
        o Criteria 5:
           Age >18 years, AND
           Submitted ICD-9 diagnosis code for Crohn’s disease
              (Appendix F) or regional enteritis (Appendix F) in the past 2
              Years, AND
                   Drug claim for adalimumab (Humira) in past 65 days
                      (Signifying Above Criteria Previously Met)
        o Criteria 6:
           Submitted diagnosis of psoriasis (Appendix F) in the past 2
              years, AND
           Age >18, AND
           Paid Drug claim for adalimumab (Humira) in past 45 days
              (Signifying Above Criteria Previously Met)
        o Criteria 7:
           Submitted diagnosis of psoriasis (Appendix F) in the past 2
              years, AND
           Age >18, AND
           During days 180 to 395 days ago, a total of >180 days of
              topical drug therapy with: anthralin, calcipotriene,
              corticosteroids, or tazarotene in past 395 days, AND
           During days 1-210 ago, a total of >180 days of systemic drug
              therapy with: cyclosporine, methotrexate, or acitretin, AND
           Topical drug therapy trial occurred before systemic drug
              therapy
        o Criteria 8:
           Submitted ICD-9 diagnosis of rheumatoid arthritis (Appendix
              F) in past 2 years, AND
           Age <18

   Approval criteria for Raptiva
    Must meet all criteria in either Criteria 1 or Criteria 2 for approval:
        o Criteria 1:
            Submitted diagnosis of psoriasis (Appendix F) in the past 730
               days , AND
            Age >17, AND
            Drug claim for efalizumab/Raptiva® in past 45 days
        o Criteria 2:
            Submitted diagnosis of psoriasis (Appendix F) in the past 730
               days , AND
            Age >17, AND
            During days 180 to 395 days ago, a total of >180 days of
               topical drug therapy with:
                           anthralin,
                           calcipotriene,
                           corticosteroids, or
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Arkansas Medicaid Prescription Drug Program
    Preferred Drug List Criteria Overview
                   tazarotene in past 395 days, AND
         During days 1-210 ago, a total of >180 days of systemic drug
          therapy with:
                   cyclosporine,
                   methotrexate, or
                   acitretin, AND
         Topical drug therapy trial occurred before systemic drug
          therapy




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       Preferred Drug List Criteria Overview

 Non-Benzodiazepine Sedative Hypnotics
Preferred agents with criteria:
      Ramelton (Rozerem)
      Zaleplon (Sonata)
      Zolpiedem immediate release (Ambien)

Non-preferred agents:

      Eszopiclone (Lunesta)
      Zolpiedem extended release (Ambien CR)
      Zolpiedem sublingual tablets (Edular)



Denial criteria:
      Therapeutic Duplication with other sedative hypnotics




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 5-HT3 or NK1 Receptor Antagonists
Preferred agents with criteria:
      Ondansetron 2mg and 4mg tablets (Zofran)
      Ondansetron 2mg and 4mg oral disintegrating tablets (Zofran)
      Ondansetron 4mg/2ml preservative free vials (Zofran)
      Ondansetron 40mg/20ml vials (Zofran)

Non-preferred agents:

      Aprepitant (Emend)
      Dolasetron (Anzemet)
      Granisetron (Kytril, Sancuso)
      Ondansetron 24mg tablet (Zofran)
      Ondansetron 32mg/50ml bag (Zofran)
      Ondansetron 4mg/5ml solution (Zofran)
      Ondansetron 4mg/2ml ampules and syringes (Zofran)

Denial criteria:
      Therapeutic Duplication with other 5-HT3 receptor antagonists




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 Overactive Bladder Agents
Preferred agents:
      Darifenacin (Enablex)
      Oxybutynin 5mg tablet (Ditropan)
      Oxybutynin 5mg/5ml syrup (Ditropan)
      Solfenacin (Vesicare)
      Trospium XR (Sanctura XR)

Preferred agents with criteria:

      Oxybutynin XL tablet (Ditropan XL Tablet)

Non-preferred agents:

      Fesoterodine (Toviaz)
      Flavoxate (Urispas)
      Oxybutynin Gel (Gelnique)
      Oxybutynin Patch (Oxytrol)
      Tolterodine (Detrol and Detrol LA)
      Trospium IR (Sanctura)

Approval criteria:
      Oxybutynin XL Tablet
         o Ages 6 – 18, AND
         o Diagnosis of spina bifida (Appendix H)




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 Second Generation Antidepressants (SGAD)
Preferred agents with criteria:
      Bupropion hydrochloride (Wellbutrin)
      Bupropion hydrochloride extended release (Wellbutrin XL)
      Bupropion hydrochloride sustained release (Wellbutrin SR)
      Citalopram hydrobromide (Celexa)
      Bupropion extended release 150 mg and 300 mg tablet (Wellbutrin XL)
      Escitalopram oxalate (Lexapro)
      Fluoxetine hydrochloride 10 mg capsule, 20 mg capsule, and 20 mg/5 ml
       solution (Prozac)
      Fluvoxamine maleate (Luvox and Luvox CR)
      Mirtazapine 15 mg, 30 mg, 45 mg tablet (Remeron)
      Paroxetine hydrochloride 10 mg, 20 mg, 30 mg, and 40 mg tablet (Paxil)
      Sertraline hydrochloride (Zoloft)
      Venlafaxine hydrochloride regular release tablet (Effexor)

Non-preferred agents with SGAD criteria:
      Bupropion hydrobromide extended release tablet (Aplenzin)
      Desvenlafaxine succinate (Pristiq)
      Duloxetine hydrochloride (Cymbalta)
      Fluoxetine hydrochloride 10 mg tablet, 15 mg tablet, 20 mg tablet, 40 mg
       capsule, and 90 mg weekly capsule (Prozac)
      Mirtazapine 7.5 mg tablet and RPD tablet (Remeron RPD)
      Milnacipran hydrochloride (Savella)
      Nefazodone hydrochloride (Serzone)
      Paroxetine hydrochloride controlled release tablet and 10 mg/5 ml
       suspension (Paxil)
      Paroxetine mesylate (Pexeva) Eff 1/1/2010
      Venlafaxine hydrochloride extended release capsule (Effexor ER)
      Venlafaxine hydrochloride extended release tablet

Exempt SGAD combination agents with criteria:
      Fluoxetine hydrochloride/olanzapine (Symbyax)

Approval criteria for all agents except milnacipran:
      >=90 days of therapy in the previous 120 days for the same drug,
       strength, and daily dose with the denial exception of a therapeutic


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       duplication between a SSRI and/or SNRI between in-coming claim and
       history

Approval criteria for preferred or exempt agents:
      Drug daily dose <= maximum daily dose (Appendix I)

Approval criteria for preferred or exempt agents resulting
from a therapeutic duplication:
      If applicable for a change in therapy or concomitant therapy of 2 agents
       and only one or neither are SSRIs and/or SSNRIs (including
       combinations) (Appendix J):
           o Drug in history reflects a minimal therapeutic dose (Appendix I) for
               at least four weeks

       OR

      If applicable for a change in therapy for 2 SSRIs and/or SSNRIs (including
       combinations) (Appendix J)
           o Drug in history reflects a minimal therapeutic dose (Appendix I) for
               at least four weeks, AND
           o No prior therapeutic duplication for 2 different SSRIs and/or
               SSNRIs (including combinations) (Appendix J) within the past 365
               days

Approval criteria for milnacipran:
      Diagnosis of fibromyalgia

Denial criteria:
      Preferred agents or exempt agents
          o Therapeutic duplication of 3 agents
          o Therapeutic duplication of 2 SSRIs and/or SSNRIs (including
              combinations) (Appendix J) more than once per 365 days
      Non-preferred drugs for patients who do not meet criteria of >=90 days of
       therapy in the previous 120 days for the same drug, strength, and daily
       dose




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 Nonsteroidal Antiinflammatory Agents
Preferred agents:
      Ibuprofen 100 mg/5 ml suspension; 400 mg, 600 mg, 800 mg tablet
       (Motrin)
      Indomethacin 25 mg capsule (Indocin)
      Ketoprofen 50 mg and 75 mg capsule (Orudis)
      Meloxicam 7.5 mg and 15 mg tablet (Mobic)
      Naproxen 250 mg, 375 mg, and 500 mg tablet (Naprosyn)
      Naproxen 375 mg and 500 mg tablets enteric coated (EC-Naprosyn)
      Naproxen sodium 275 mg and 550 mg tablet (Anaprox)
      Piroxicam (Feldene)
      Salsalate (Salflex)

Preferred agents with criteria:

      Ketorolac (Toradol)

Non-preferred agents:

      Celecoxib (Celebrex)
      Diclofenac (Cataflam, Flector, Solaraze, Voltaren, Zipsor)
      Diclofenac/Misoprostol (Arthrotec)
      Diflunisal (Dolobid)
      Etodolac (Lodine)
      Fenoprofen (Nalfon)
      Flurbiprofen (Ansaid)
      Ibuprofen 40 mg/ml suspension; 50 mg and 100 mg tablet (Motrin)
      Indomethacin 50 mg, 75 mg SA capsule; suppository, 25 mg/5 ml
       suspension (Indocin)
      Ibuprofen/caffeine/B1/B2/B6/B12
      Ketoprofen 200 mg capsule SA (Oruvail)
      Meclofenemate (Meclomen)
      Mefenamic acid (Ponstel)
      Meloxicam suspension (Mobic)
      Nabumetone (Relafen)
      Naproxen suspension (Naprosyn)
      Naproxen sodium 375 mg and 500 mg tablet SA (Naprelan)
      Oxaprozin (Daypro)
      Sulindac (Clinoril)
      Tolmetin (Tolectin)

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Denial criteria for preferred agents:
      Ketorolac
          o History of ketorolac use in the last 60 days, OR
          o NSAID claim in the past 30 days, OR
          o Dose greater than 4 per day, OR
          o Days supply greater than 5, OR
          o Quantity greater than 20, OR
          o Greater than 20 units per 60 days




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 Attention Deficit Disorder and Attention
 Deficit Hyperactivity Disorder (ADD/ADHD)
 Agents
Preferred agents with criteria:
       Amphetamine salts ER capsule (Adderall XR)
       Amphetamine salts tablet (Adderall)
       Atomoxetine (Strattera)
       Dexmethylphenidate extended release capsule (Focalin XR)
       Dexmethylphenidate tablet (Focalin)
       Dextroamephetamine tablets
       Lisdexamfetamine (Vyvanse)
       Methylphenidate swallow tablet (Ritalin)
       Methylphenidate ER tablet (Concerta)
       Methylphenidate ER patch (Daytrana)

Non-preferred agents:

       Dextroamephetamine capsules and liquid (Dexedrine, Liquadd)
       Guanfacine extended release table (Intuniv ER)
       Methamphetamine (Desoxyn)
       Methylphenidate chewable tablets (Methylin)
       Methylphenidate solution (Methylin)
       Methylphenidate sustained action capsule (Metadate CD, Ritalin LA)
       Methylphenidate sustained action tablet (Ritalin SR)

Approval criteria for preferred agents with criteria:
 Atomoxetine
   No therapeutic duplication with a different ADD/ADHD with different GCN in
     history with >25% remaining days supply

 Dexmethylphenidate immediate release
   No therapeutic duplication with atomoxetine in history with >25% remaining
    days supply

 All Extended Release CII Stimulants
 Criteria 1:
   <=1 Therapeutic duplication with the same prescriber ID and different date
      of service between long-acting C-II stimulants with 75% of the last fill per 93
      days
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Criteria 2:
  Allow one therapeutic duplication for the same subset of drugs for the same
     date of service from the same prescriber from the same pharmacy for
     predetermined total daily max milligrams that are not commercially
     available:
     o Adderall XR (17459, 17468, 17469, 14635, 14636, 14637) = 35mg,
         45mg , or 55mg
     o Concerta (12567, 17123, 12568, 12248) = 45mg, 63mg, 81mg, or 90mg
     o Daytrana (26801, 26802, 26803, 26804) = 25mg, 35mg 45mg, 50mg
     o Focalin XR (24733, 24734, 97111, 24735) = 25mg, 35mg

All Immediate Release CII Stimulants excluding dexmethylphenidate
immediate release
   <= 1 Therapeutic duplication with the same prescriber ID and different date
     of service between short-acting C-II stimulants with 75% of the last fill per
     93 days




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 Neuropathic Pain Agents
 Medications listed as either preferred or non-preferred status in this category
 may or may not include an FDA approved indication for neuropathic pain. Use of
 these medications for neuropathic pain and neuralgias has been reviewed
 through the evidence-based review process. Medications listed in this category
 as either preferred or non-preferred status are not to be construed as
 endorsements for marketing of off-label use by the manufacturer or by Medicaid.
Preferred agents no criteria:
       Amitriptyline (Elavil)
       Carbamazepine chewable tablet (Tegretol Tablet Chewable)
       Carbamazepine immediate release tablet (Tegretol)
       Gabapentin capsules (Neurontin)
       Gabapentin tablets, 600mg and 800mg ( Neurontin)
       Nortriptyline (Pamelor)

Preferred agents with criteria:
       Pregabalin (Lyrica)
       Venlafaxine (Effexor) – see Second Generation Antidepressant

Non-preferred agents with criteria:

       Carbamazepine extended release capsule (Carbatrol SA)
       Carbamazepine extended release tablet (Tegretol XR)
       Carbamazepine suspension (Tegretol)
       Divalproex sodium (Depakote)
       Duloxetine (Cymbalta) – see Second Generation Antidepressant
       Gabapentin 250mg/5ml solution (Neurontin)
       Gabapentin tablets, 100mg, 300mg, and 400mg
       Lacosamide (Vimpat)
       Lamotrigine (Lamictal)
       Lidocaine patch (Lidoderm)
       Oxcarbazepine (Trileptal)
       Topiramate (Topamax)
       Valprioc acid (Depakene, Stavzor)
       Venlafaxine capsules, extended release (Effexor XR) – see Second
        Generation Antidepressant




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Approval criteria for pregabalin (Lyrica):
      No therapeutic duplication with pregabalin, OR
      One therapeutic duplication (75% overlap of last fill) with different date of
       service and same prescriber ID between Lyrica GCNs in previous 93 days

Approval criteria for non-preferred anti-epileptic agents:
  Non-Preferred Antiepileptic Agents (Appendix L)
   One or more of the approved diagnoses (Appendix M)

  Non-Preferred lamotrigine ODT (Lamictal ODT)
   NPO (Appendix E), AND
   One or more of the approved diagnoses (Appendix M)


 Approval criteria for non-preferred topical analgesia
      Submitted ICD-9 diagnosis post-herpetic neuralgia (Appendix N) within the
       past 12 months, OR
      Paid claim in history identifying appropriate antiviral medication (Appendix
       O) for post-herpetic neuralgia (Appendix N) within the past 30 days




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 Hormone Replacement Agents
Preferred agents:
      Estradiol oral tablerts, 0.5mg, 1mg, 2mg (Estrace)
      Estropipate oral tablet (Ogen)

Non-preferred agents with criteria:

      Estradiol/drospirenone (Angeliq)
      Estradiol/levonorgestrel (Climara Pro)
      Estradiol/norethindrone (Activella)
      Estradiol/norgestimate (Prefest)
      Estrogens, conjugated/medroxyprogesterone (Premphase, Prempro)
       effective 7/11/2008
      Ethinyl estradiol/norethindrone acetate (Femhrt)

Non-preferred agents no criteria:

      Estradiol acetate tablet (Femtrace)
      Estradiol acetate vaginal ring (Femring)
      Estradiol 1.5mg oral tablet (Estrace)
      Estradiol spray (Evamist)
      Estradiol topical gel (Divigel)
      Estradiol transdermal (Alora, Climara)
      Estradiol vaginal ring (Estring)
      Estradiol vaginal tablet (Vagifem)

Approval criteria for preferred agents with criteria:
      >=120 days of therapy in the previous 180 days for the same drug,
       strength, and dosage form




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 Short Acting Bronchodilators – Quick Relief
 Asthma Drugs
SABA Preferred agents:
      Albuterol 90 mcg inhaler (Proventil)
      Albuterol 5 mg/ml solution (Proventil)
      Albuterol 0.83 mg/ml solution (Proventil)
      Albuterol HFA inhaler (ProAir HFA)
      Albuterol HFA inhaler (Ventolin HFA)
      Pirbuterol inhaler (Maxair Autohaler)

Non-preferred agents with criteria:

      Ipratropium (Atrovent)
      Albuterol/Ipratropium (Combivent, Duoneb)

Non-preferred agents:

      Albuterol 0.21 mg/ml solution (Accuneb)
      Albuterol 0.42 mg/ml solution (Accuneb)
      Albuterol 2.5 mg/0.5 ml solution
      Albuterol HFA (Proventil HFA)
      Levalbuterol inhaler and solution (Xopenex)
      Metaproterenol inhaler and solution (Alupent)

Approval criteria for non-preferred agents with criteria:
   One of the following diagnoses or procedures:
    Anoxic brain injury (348.1)
    COPD (Appendix K)
    Heart transplant (V421)
    Quadriplegic cerebral palsy (343.2)
    Respiratory insufficiency (Appendix G)
    Tracheostomy (Appendix P)
    Trachoemalacia congenital (748.3)




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 Inhaled Corticosteroids – Controller Asthma
 Drugs
Preferred agents:
      Beclomethasone dipropionate inhaler (QVAR)
      Fluticasone 50mcg disk with device (Flovent Diskus)
      Fluticasone HFA (Flovent HFA Inhaler)
      Mometasone (Asmanex Inhaler 30, 60, 120)

Non-preferred agents:

      Budesonide inhaler (Pulmicort Flexhaler)
      Ciclesonide (Alvesco)
      Flunisolide inhaler (Aerobid)
      Flunisolide M inhaler (Aerobid M)
      Fluticasone 100mcg and 250mcg disk with device (Flovent Diskus)
       effective 8/11/2009
      Mometasone (Asmanex Inhaler 14)
      Triamcinolone acetonide inhaler (Azmacort)

Non-preferred agents with criteria:

      Budesonide respules (Pulmicort Respules)

Approval criteria:
      Budesonide respules
         o < 4 years of age




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 Long Acting Beta2 Agonist – Controller
 Asthma Drugs
LABA Non-preferred agents with criteria:

      Arformoterol nebulizer (Brovana)
      Formoterol Inhaler (Foradil)
      Formoterol nebulizer (Perforomist)
      Salmeterol Inhaler (Serevent Diskus)

Approval criteria for non-preferred agents with criteria:
      COPD (Appendix K)




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 Inhaled Beta2 Agonist and Corticosteroid
 Combination – Controller Asthma Drugs
LABA ICS Preferred agents with criteria:
      Budesonide/Formoterol (Symbicort)
      Fluticasone/Salmeterol HFA (Advair HFA)

Non-preferred agents with criteria:

      Fluticasone/Salmeterol (Advair Diskus)

Approval criteria for preferred agents with criteria:
       Criteria 1: COPD (Appendix K)

       OR

       Criteria 2:
              A. Paid Drug claim in drug history for a beta2 agonist/corticosteroid
                 combination product in the last 6 months
              B. One of the following criteria below:
                  >3 inhaled corticosteroid claims in the last 120 days, OR
                  > 3 oral steroid claims in the last 120 days, OR
                  Combination for >3 claims (as defined below) in the last 120
                   days:
                       o 1 Inhaled Corticosteroid + 2 Oral Steroids
                       o 2 Inhaled Corticosteroids + 1 Oral Steroids

Approval criteria for non-preferred agents with criteria:
       Criteria 1: COPD (Appendix K)




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 Leukotriene Receptor Antagonists
LTRA Preferred agents with criteria:
      Montelukast (Singulair)

Non-preferred agents:

      Zafirlukast (Accolate)
      Zileuton (Zyflo)

Approval criteria for preferred agents with criteria:
       Criteria 1:
              A. If a paid drug claim in history for an inhaled corticosteroid, long-
                 acting beta2 agonist/inhaled corticosteroid, or short-acting beta2
                 agonist in the last 365 days, then
              B. One of the following criteria below:
                  <2 claims for short-acting beta2 in the last 365 days, AND
                  <1 claim for an oral corticosteroid in the last 183 days
                 OR
                  IF the patient exceeds any of the above criteria, then the
                    asthma patient must have a claim for an inhaled asthma
                    controller (ICS or ICS/LABA) in Medicaid drug history in last
                    45 days.

       OR

       Criteria 2:
              A. If no paid drug claim in history for an inhaled corticosteroid,
                 long-acting beta2 agonist/inhaled corticosteroid, or short-acting
                 beta2 agonist in the last 365 days, then
              B. One of the following criteria below:
                  >1 claim for an inhaled nasal steroid from the 7th day to
                   the124th day in Medicaid history, OR
                   >1 claim for a second generation antihistamine from the 7th
                   day to the124th day in Medicaid history




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 Top of the Document


 Appendix
Appendix A – Congestive Heart Failure

 ICD-9                                          Description
402.01    Hypertensive heart disease with heart failure
402.11    Hypertensive heart disease with heart failure
402.91    Hypertensive heart disease with heart failure
404.01    Hypertensive heart and renal disease with heart failure
404.03    Hypertensive heart and renal disease with heart and renal failure
404.11    Hypertensive heart and renal disease with heart failure
404.13    Hypertensive heart and renal disease with heart and renal failure
404.91    Hypertensive heart and renal disease with heart failure
404.92    Hypertensive heart and renal disease with renal failure
404.93    Hypertensive heart and renal disease with heart and renal failure
428       Congestive heart failure, unspecified



Appendix B – Malignant Cancer Diagnoses

ICD-9                                           Description
140      Malignant neoplasm of lip
142      Malignant neoplasm of major salivary gland
146      Malignant neoplasm of oropharynx
147      Malignant neoplasm of nasopharynx
148      Malignant neoplasm of hypopharynx
149      Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
150      Malignant neoplasm of esophagus
151      Malignant neoplasm of stomach
152      Malignant neoplasm small intestine including duodenum
153      Malignant neoplasm of colon
154      Malignant neoplasm rectum rectosigmoid junction
155      Malignant neoplasm of liver and intrahep
156      Malignant neoplasm gall bladder and extrahepatic bile duct
157      Malignant neoplasm of pancreas
158      Malignant neoplasm of retroperitoneum and peritoneum
         Malignant neoplasm of other and ill-defined sites within the digestive organs and
159      peritoneum
160      Malignant neoplsm nasal cavities middle ear and accessory sinuses
161      Malignant neoplasm of larynx
162      Malignant neoplasm of trachea bronchus and lung
163      Malignant neoplasm of pleura
164      Malignant neoplasm of thymus, heart, and mediastinum
165      Malignant neoplasm of other and ill-defined sites within the respiratory system and

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        intrathoracic organs
170     Malignant neoplasm of bone and articular cartilage
171     Malignant neoplasm connective and other soft tissue
172     Malignant melanoma of skin
174     Malignant neoplasm of female breast
175     Malignant neoplasm of male breast
176     Kaposis sarcoma
179     Malignant neoplasm of uterus, part unspecified
180     Malignant neoplasm of cervix uteri
181     Malignant neoplasm of placenta
182     Malignant neoplasm of body of uterus
183     Malignant neoplasm of ovary and other uterine adnexa
184     Malignant neoplasm other and unspecified female genital organs
185     Malignant neoplasm of prostate
186     Malignant neoplasm of testis
187     Malignant neoplasm penis and other male genital
188     Malignant neoplasm of bladder
189     Malignant neoplasm kidney and other and unspecified urinary organs
190     Malignant neoplasm of eye
191     Malignant neoplasm of brain
192     Malignant neoplasm other and unspecified parts nervous system
193     Malignant neoplasm of thyroid gland
194     Malignant neoplasm other endocrine glands and related structures
195     Malignant neoplasm of other and ill-defined sites
196     Secondary and unspecified malignant neoplasm lymph
197     Secondary malignant neoplasm respiratory and digestive
198     Secondary malignant neoplasm of other specified sites
199     Malignant neoplasm without specification
200     Lymphosarcoma and reticulosarcoma
201     Hodgkins disease
202     Other malignant neoplasms lymphoid and histiocytic tissue
203     Multiple myeloma and immunoproliferative neoplasms
204     Lymphoid leukemia
205     Myeloid leukemia
206     Monocytic leukemia
207     Other specified leukemia
208     Leukemia of unspecified cell type



Appendix C – Antineoplastics to Infer Malignant Cancer

                                     Antineoplastics
Aldesleukin
Alemtuzumab
Altretamine
Amifostine
Arsenic

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Asparaginase
Bcg
Bevacizumab
Bleomycin
Busulfan
Capecitabine
Carboplatin
Carmustine
Cisplatin
Clofarabine
Cytarabine
Dacarbazine
Dactinomycin
Daunorubicin
Denileukin
Docetaxel
Doxorubicin
Estramustine
Etoposide
Exemestane
Floxuridine
Fludarabine
Fluorouracil
Fulvestrant
Gefitinib
Gemcitabine
Gemtuzumab
Idarubicin
Ifosfamide
Ifosfamide/mesna
Imatinib
Lomustine
Mechlorethamine
Mitomycin
Mitoxantrone
Oxaliplatin
Paclitaxel
Paclitaxel,semi-synthetic
Pegaspargase
Pemetrexed
Pentostatin
Plicamycin
Procarbazine
Rasburicase
Rituximab
Streptozocin
Temozolomide
Teniposide
Thiotepa
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Topotecan
Trastuzumab
Vinblastine
Vincristine
Vinorelbine



Appendix D – Skeletal Muscle Relaxants Diagnoses

ICD-9                                           Description
333.7    Symptomatic torsion dystonia
340      Multiple sclerosis
342.1    Spastic hemiplegia
343      Infantile cerebral palsy
345.6    Infantile spasms
430      Subarachnoid hemorrhage
431      Intracerebral hemorrhage
432      Other and unspecified intracranial hemorrhage
433.x1   Occlusion and stenosis of precerebral arteries with cerebral infarction
767.4    Injury to spine and spinal cord
781.0    Abnormal involuntary movements
806      Fracture of vertebral column with spinal cord injury
851      Cerebral laceration and contusion
900      Injury to blood vessels of head and neck
907.2    Late effect of spinal cord injury
952      Spinal cord injury without evidence of spinal bone injury



Appendix E – Nil per os (NPO)

ICD-9/Procedure Codes                                    Description
B4034, B4035, B4036         Enteral feeding supplies
B4149, B4150-B4156          Enteral formula
B4160-B4162                 Enteral formula for pediatrics
43.11                       PEG
46.32                       PEJ tube
96.07                       Nasogastric tube insertion
97.01                       Nasogastric tube placement
432.46                      PEG placement
432.60                      PEG placement
437.52                      Naso/Oro-gastric tube placement
437.6                       Gastrostomy tube
437.61                      G-tube repositioning
438.3                       Gastrostomy tube
438.32                      Gastrostomy tube
440.15                      J-Tube

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443.72                      J-Tube
443.73                      J-Tube
494.4                       PEG placement



Appendix F – Targeted Immune Modulator Diagnoses

  Drug       ICD-9                                   Description
Enbrel      696.0     Psoriatic arthropathy
Enbrel      696.1     Other psoriasis
Enbrel      714       Rheumatoid arthritis and other inflammatory polyarthropathies
Enbrel      720       Ankylosing spondylosis

Humira      555       Crohn's disease
Humira      555       Regional enteritis
Humira      565.1     Anal fistula
Humira      696.0     Psoriatic arthropathy
Humira      567.2     Peritonitis (acute) generalized
Humira      567.2     Peritoneal abscess
Humira      567.2     Spontaneous bacterial peritonitis
Humira      567.3     Other suppurative peritonitis
Humira      567.3     Retroperitoneal infections
Humira      567.3     Psoas muscle abscess
Humira      567.4     Other retroperitoneal abscess
Humira      567.4     Other retroperitoneal infections
Humira      567.8     Choleperitonitis
Humira      567.8     Sclerosing mesenteritis
Humira      567.9     Other specified peritonitis
Humira      569.8     Fistula of intestine excluding rectum an
Humira      696.1     Other psoriasis
Humira      714       Rheumatoid arthritis and other inflammatory polyarthropathies
Humira      720       Ankylosing spondylosis

Raptiva     696.1     Other psoriasis



Appendix G – Respiratory Insufficiency Diagnoses

 ICD-9                                         Description

518.82    Other pulmonary insufficiency, not elsewhere classified
518.83    Chronic respiratory failure
518.84    Acute and chronic respiratory failure




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Appendix H – Spinal Bifida Diagnoses

 ICD-9                                    Description
741      Spinal bifida



Appendix I – Minimum and Maximum Dose for Second
Generation Antidepressants


            Drug             Minimal Daily Therapeutic Dose     Maximum Daily Dose
  Bupropion                 200 mg                            450 mg
  Citalopram                20 mg                             60 mg
  Desvenlafaxine            50 mg                             100 mg
  Duloxetine                40 mg                             60 mg
  Escitalopram              10 mg                             30 mg
  Fluoxetine                20 mg                             80 mg
  Fluoxetine/olanzapine*    25 mg                             75 mg
  Fluvoxamine               100 mg                            300 mg
  Mirtazapine               30 mg                             60 mg
  Nefazodone                300 mg                            600 mg
  Paroxetine                30 mg                             60 mg (CR 62.5 mg)
  Sertraline                100 mg                            200 mg
  Venlafaxine               150 mg                            375 mg

* Minimum therapeutic dose and maximum dose based on SSRI component of the combination
agent.



Appendix J – Selective Serotonin (Norepinephrine)
Reuptake Inhibitors (Combinations)

                           SSRI, SSNRI or SSRI Combinations
Citalopram
Desvenlafaxine
Duloxetine
Escitalopram
Fluoxetine
Fluoxetine/olanzapine
Fluvoxamine
Paroxetine
Sertraline
Venlafaxine


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Appendix K – Chronic Obstruction Pulmonary Disease
Diagnoses

 ICD-9                                         Description
491       Chronic bronchitis
492       Emphysema
493.2     Chronic obstructive asthma
496       Chronic airway obstruction, not elsewhere classified



Appendix L – Non-Preferred Antiepileptic Agents in
Neuropathic Pain Agent Class

                                       Antiepileptic
Carbamazepine extended release capsule (Carbatrol SA)
Carbamazepine extended release tablet (Tegretol XR)
Carbamazepine suspension (Tegretol)
Divalproex sodium (Depakote)
Gabapentin 250mg/5ml solution (Neurontin)
Gabapentin tablets, 100mg, 300mg, and 400mg
Lamotrigine (Lamictal)
Oxcarbazepine (Trileptal)
Topiramate (Topamax)
Valprioc acid (Depakene, Stavzor)



Appendix M – Approved Diagnoses for Non-Preferred
Antiepileptic Agents in Neuropathic Pain Agent Class

  ICD-9                                          Description
46.2        Subacute sclerosing panencephalitis
54.3        Herpes simplex meningoencephalitis
238.7       Other lymphatic and hematopoietic tissues
253.5       Diabetes insipidus
291.81      Alcohol withdrawal
292         Drug withdrawal syndrome
293.81      Pyschotic disorder with delusions in conditions classifed elsewhere
293.82      Pyschotic disorder with hallucinations in conditions classifed elsewhere
294.1XX     Dementia in conditions classified elsewhere
295.XX      Schizophrenic disorders
296.XX      Affective pyschoses (manic, depressive, bi-polar)
299.XX      Pyschoses with origin specific to childhood (pervasive developemental disorders)
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300.01   Panic disorder
300.23   Social phobia
300.3    Obsessive compulsive disorder
300.4    Neurotic depression
301.12   Chronic depressive personality disorder
301.2    Schizoid personality disorder
301.4    Obsessive compulsive disorder
301.83   Borderline personality disorder
304.2    Cocaine dependence
306.1    Physiological malfunction arising from mental factors, respiratory
307.2X   Tics
307.81   Tension headache
308.2    Predominant psychomotor disturbance
309.XX   Adjustment reaction
310.9    Unspecified nonpsychotic mental disorder following organic brain damage
311      Depressive disorder
312.X    Disturbance of conduct
313.XX   Disturbance of emotions specific to childhood adolescence
317.XX   Mild mental retardation
318.XX   Other specified mental retardation
319.XX   Unspecified mental retardation
327.51   Periodic limb movement disorder
330.1    Cerebral lipidoses
330.8    Rett's disorder
332.XX   Parkinson's disease
333.XX   Other extrapyramidal disease and abnormal movement disorder
340      Multiple sclerosis
345.XX   Epilepsy
346.XX   Migraine
353.6    Phantom limb syndrome
359.2    Myotonic disorder
368.16   Psychophysical visual disturbance
388.3X   Tinnitis
392.XX   Rheumatic chorea
438.81   Apraxia
588.1    Nephrogenic diabetes insipidus
625.4    Premenstrual tension syndromes
696.1    Erythrodermic psoriasis
759.81   Prader-willi syndrome
759.89   Angelman syndrome
779.XX   Other and ill defined conditions originating in the perinatal period
780.3X   Convulsions, seizures
781.XX   Abnormal involuntary movements
784.69   Symbolic dysfunction, unspecified, other
786.8    Hiccough
854.XX   Intracranial injury
V11.0    Schizophrenia
V11.1    Affective disorders
V11.3    Alcoholism
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V17.2        Other neurological diseases
V18.4        Mental retardation
V79.0        Depression
V79.2        Mental retardation



Appendix N – Postherpetic Neuralgia Diagnosis

 ICD-9                                           Description
  53.12   Postherpetic trigeminal neuralgia
  53.13   Postherpetic polyneuropathy



Appendix O – Antivirals

                                              Antivirals
Acyclovir 200 MG
Acyclovir 200 MG
Acyclovir 400 MG
Acyclovir 800 MG
Famciclovir 125 MG
Famciclovir 250 MG
Famciclovir 500 MG
Valacyclovir 1 GM Caplet
Valacyclovir 500 MG Caplet



Appendix P – Tracheostomy

ICD-9                                        Description
  31.1    Temporary tracheostomy
 31.74    Revision of tracheostomy
316.00    Tracheostomy, planned (separate procedure);
316.01    Tracheostomy, planned (separate procedure); younger than two years
316.03    Tracheostomy, emergency procedure; transtracheal
316.05    Tracheostomy, emergency procedure; cricothyroid membrane
316.10    Tracheostomy, fenestration procedure with skin flaps
 31.2X    Permanent tracheostomy
519.0X    Tracheostomy complications
 V44.0    Tracheostomy status
 V55.0    Attention to tracheostomy




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Appendix Q




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