Dextromethorphan Overutilization

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1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs Requiring PA: the list of drugs requiring prior authorization for this clinical edit Drug Classification: classification of each drug requiring PA Age and Dosing Limits: the maximum dose/day based on client s age and drug classification Note: Click the hyperlink to navigate directly to that information. Revision Notes Initial publication and posting to website July 18, 2012 Copyright 2012 Health Information Designs, LLC 1

2 Drug Classification 1. Obtain the client s age. (Make a note of it for future reference.) 2. In the following table, locate the Classification associated with the incoming request 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 and Dosing Limits page. Drugs Requiring PA Label Name GCN Classification ALA-HIST DM LIQUID Appendix L ALLFEN DM TABLET Appendix A ALL-NITE LIQUID Appendix N ATUSS DS SUSPENSION Appendix I BP 8 COUGH ORAL SUSPENSION Appendix L BPM-PSE-DM LIQUID Appendix K BROMALINE DM COLD-COUGH ELX Appendix N BROMFED DM COUGH SYRUP Appendix M BROTAPP DM LIQUID Appendix N BROVEX PEB DM LIQUID Appendix K BROVEX PSB DM LIQUID Appendix K CARDEC DM DROPS Appendix F CENTERGY DM PEDIATRIC DROPS Appendix F CHILDREN COLD & COUGH DM ELIXI Appendix N CHILDREN'S MUCINEX COUGH LIQ Appendix N CHLORPHEN-PSE-DM TANNATE SUSP Appendix I CORFEN-DM LIQUID Appendix L COUGH & SORE THROAT LIQUID Appendix N CPM-PSE DM DROPS Appendix F DALLERGY DM SYRUP Appendix L DAYTIME LIQUID CAPSULE Appendix D DE-CHLOR DM LIQUID Appendix L DECONEX DM CAPSULE Appendix C DECONEX DMX TABLET Appendix C DECONSAL DM TABLET CHEW Appendix C DELSYM 30 MG/5 ML SUSPENSION Appendix I DELSYM COUGH-COLD NIGHTIME LIQ Appendix N DELSYM MULTI-SYMPTOM NIGHT LIQ Appendix O DIMAPHEN DM ELIXIR Appendix N July 18, 2012 Copyright 2012 Health Information Designs, LLC 2

3 Drugs Requiring PA Label Name GCN Classification DIMETANE-DX LIQUID Appendix M DONATUSSIN DM DROPS Appendix F DURAFLU TABLET Appendix A ENDACOF DROPS Appendix H ENTRE-S SUSPENSION Appendix I EXTRA ACTION COUGH SYRUP Appendix M FLUTABS TABLET Appendix A GUAIFENESIN DM SYRUP Appendix M INDAMIX DM SUSPENSION Appendix J IOPHEN DM-NR LIQUID Appendix M KIDKARE COUGH & COLD LIQUID Appendix N LOHIST PEB DM LIQUID Appendix K LOHIST-DM SYRUP Appendix M LOHIST-PSB-DM LIQUID Appendix K MAPAP COLD FORMULA CAPLET Appendix D MAXICHLOR DM TABLET Appendix A MAXIFED DM TABLET Appendix A MAXIFED DMX TABLET Appendix A MAXIFLU DM TABLET Appendix A MAXIPHEN DM TABLET Appendix A MEDI-TUSSIN DM DIABETIC LIQ Appendix M MEDI-TUSSIN DM SYRUP Appendix M MUCINEX COUGH MINI-MELT PACK Appendix E MUCINEX DM ER MG TABLET Appendix Q MUCINEX DM ER 1, MG TAB Appendix P MUCINEX FAST-MAX DM MAX LIQUID Appendix N MYHIST-DM LIQUID Appendix N NASOHIST DM PEDIATRIC DROPS Appendix F NEO DM DROPS Appendix G NEO DM SUSPENSION Appendix I NEO DM SYRUP Appendix I NEUTRAHIST PDX DROPS Appendix F NIGHT TIME LIQUID CAPSULE Appendix C NOHIST-DM LIQUID Appendix L PAIN RELIEF COLD PE CAPLET Appendix C PEDIATRIC COUGH-COLD LIQUID Appendix N PE-HIST DM SYRUP Appendix L PHENFLU DM TABLET Appendix A POLY-VENT DM TABLET Appendix C PROMETHAZINE-DM SYRUP Appendix L PSE BROM DM SYRUP Appendix I PYRIL DM SUSP Appendix L July 18, 2012 Copyright 2012 Health Information Designs, LLC 3

4 Drugs Requiring PA Label Name GCN Classification QC DAYTIME LIQUID CAPSULE Appendix D QC NIGHTTIME COUGH LIQUID Appendix N QC NIGHTTIME LIQUID CAPS Appendix C QC TUSSIN DM SYRUP Appendix M Q-TAPP DM ELIXIR Appendix N Q-TUSSIN DM SYRUP Appendix M Q-TUSSIN-DM SYRUP Appendix M RESCON-DM LIQUID Appendix M RESPERAL-DM DROPS Appendix B ROBAFEN-DM CLEAR SYRUP Appendix M ROBAFEN-DM SYRUP Appendix M RYNEX DM LIQUID Appendix N SILPHEN DM COUGH SYRUP Appendix M SILTUSSIN DM COUGH SYRUP Appendix M SILTUSSIN DM DAS LIQUID Appendix M SM TUSSIN DM SYRUP Appendix M SUDATEX-DM TABLET Appendix A SU-TUSS DM ELIXIR Appendix K TL-DEX DM LIQUID Appendix L TL-HIST DM LIQUID Appendix L TRI-DEX PE LIQUID Appendix L TRIGOFEN DM DROPS Appendix F TUSSIN DM CLEAR LIQUID Appendix M TUSSIN DM LIQUID Appendix M TUSSIN DM SYRUP Appendix M VIRDEC DM DROPS Appendix F Y-COF DMX LIQUID Appendix L Z-COF 8 DM ORAL SUSPENSION Appendix L ZOTEX-12D SR TABLET Appendix Q July 18, 2012 Copyright 2012 Health Information Designs, LLC 4

5 Age and Dosing Limits 4. Use the classification and client s age to locate the dosing limit in the Maximum Dose/Day column. Age and Dosing Limits Classification Age Maximum Dose/Day Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix I Appendix J Appendix K Appendix L Appendix M Appendix N 6-11 years 3 units 12 years and older 6 units 2-5 years 6 ml 6-11 years 6 ml 6-11 years 4 units 12 years and older 8 units 6-11 years 6 units 12 years and older 12 units 2-5 years 6 units 6-11 years 12 units 2-5 years 6 units 6-11 years 12 units 2-5 years 11 ml 6-11 years 11 ml 2-5 years 12 ml 6-11 years 12 ml 2-5 years 5 ml 6-11 years 10 ml 12 years and older 20 ml 2-5 years 5.46 ml 6-11 years 11 ml 12 years and older 22 ml 2-5 years 7.5 ml 6-11 years 15 ml 12 years and older 30 ml 2-5 years 10 ml 6-11 years 20 ml 12 years and older 40 ml 2-5 years 15 ml 6-11 years 30 ml 12 years and older 60 ml 2-5 years 30 ml 6-11 years 60 ml July 18, 2012 Copyright 2012 Health Information Designs, LLC 5

6 Age and Dosing Limits Classification Age Maximum Dose/Day Appendix O Appendix P Appendix Q 2-5 years 90 ml 6-11 years 180 ml 12 years and older 180 ml 6-11 years 1 unit 12 years and older 2 units 6-11 years 2 units 12 years and older 4 units July 18, 2012 Copyright 2012 Health Information Designs, LLC 6

7 Publication History The Publication History records the publication iterations and revisions to this document. Notes for the most current revision are also provided in the Revision Notes on the first page of this document. Publication Date Notes 07/18/2012 Initial publication and posting to website July 18, 2012 Copyright 2012 Health Information Designs, LLC 7

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