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
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 99356 Appendix L ALLFEN DM TABLET 23807 Appendix A ALL-NITE LIQUID 20556 Appendix N ATUSS DS SUSPENSION 97532 Appendix I BP 8 COUGH ORAL SUSPENSION 99400 Appendix L BPM-PSE-DM LIQUID 99910 Appendix K BROMALINE DM COLD-COUGH ELX 12934 Appendix N BROMFED DM COUGH SYRUP 96136 Appendix M BROTAPP DM LIQUID 12934 Appendix N BROVEX PEB DM LIQUID 18314 Appendix K BROVEX PSB DM LIQUID 99910 Appendix K CARDEC DM DROPS 25730 Appendix F CENTERGY DM PEDIATRIC DROPS 98828 Appendix F CHILDREN COLD & COUGH DM ELIXI 26808 Appendix N CHILDREN'S MUCINEX COUGH LIQ 53497 Appendix N CHLORPHEN-PSE-DM TANNATE SUSP 97532 Appendix I CORFEN-DM LIQUID 19347 Appendix L COUGH & SORE THROAT LIQUID 20556 Appendix N CPM-PSE DM DROPS 98115 Appendix F DALLERGY DM SYRUP 98771 Appendix L DAYTIME LIQUID CAPSULE 25093 Appendix D DE-CHLOR DM LIQUID 13848 Appendix L DECONEX DM CAPSULE 28369 Appendix C DECONEX DMX TABLET 99656 Appendix C DECONSAL DM TABLET CHEW 97268 Appendix C DELSYM 30 MG/5 ML SUSPENSION 17802 Appendix I DELSYM COUGH-COLD NIGHTIME LIQ 20556 Appendix N DELSYM MULTI-SYMPTOM NIGHT LIQ 97134 Appendix O DIMAPHEN DM ELIXIR 26808 Appendix N July 18, 2012 Copyright 2012 Health Information Designs, LLC 2
Drugs Requiring PA Label Name GCN Classification DIMETANE-DX LIQUID 96136 Appendix M DONATUSSIN DM DROPS 26097 Appendix F DURAFLU TABLET 18533 Appendix A ENDACOF DROPS 28106 Appendix H ENTRE-S SUSPENSION 97532 Appendix I EXTRA ACTION COUGH SYRUP 53495 Appendix M FLUTABS TABLET 18533 Appendix A GUAIFENESIN DM SYRUP 53495 Appendix M INDAMIX DM SUSPENSION 97887 Appendix J IOPHEN DM-NR LIQUID 53491 Appendix M KIDKARE COUGH & COLD LIQUID 96138 Appendix N LOHIST PEB DM LIQUID 18314 Appendix K LOHIST-DM SYRUP 15847 Appendix M LOHIST-PSB-DM LIQUID 99910 Appendix K MAPAP COLD FORMULA CAPLET 27135 Appendix D MAXICHLOR DM TABLET 99966 Appendix A MAXIFED DM TABLET 99175 Appendix A MAXIFED DMX TABLET 53410 Appendix A MAXIFLU DM TABLET 99237 Appendix A MAXIPHEN DM TABLET 99499 Appendix A MEDI-TUSSIN DM DIABETIC LIQ 53491 Appendix M MEDI-TUSSIN DM SYRUP 53495 Appendix M MUCINEX COUGH MINI-MELT PACK 99068 Appendix E MUCINEX DM ER 600-30 MG TABLET 53550 Appendix Q MUCINEX DM ER 1,200-60 MG TAB 99067 Appendix P MUCINEX FAST-MAX DM MAX LIQUID 53497 Appendix N MYHIST-DM LIQUID 23797 Appendix N NASOHIST DM PEDIATRIC DROPS 98828 Appendix F NEO DM DROPS 97190 Appendix G NEO DM SUSPENSION 97187 Appendix I NEO DM SYRUP 99305 Appendix I NEUTRAHIST PDX DROPS 98115 Appendix F NIGHT TIME LIQUID CAPSULE 25094 Appendix C NOHIST-DM LIQUID 19347 Appendix L PAIN RELIEF COLD PE CAPLET 27199 Appendix C PEDIATRIC COUGH-COLD LIQUID 96138 Appendix N PE-HIST DM SYRUP 96114 Appendix L PHENFLU DM TABLET 99479 Appendix A POLY-VENT DM TABLET 99657 Appendix C PROMETHAZINE-DM SYRUP 13975 Appendix L PSE BROM DM SYRUP 94275 Appendix I PYRIL DM SUSP 27633 Appendix L July 18, 2012 Copyright 2012 Health Information Designs, LLC 3
Drugs Requiring PA Label Name GCN Classification QC DAYTIME LIQUID CAPSULE 25093 Appendix D QC NIGHTTIME COUGH LIQUID 26684 Appendix N QC NIGHTTIME LIQUID CAPS 25094 Appendix C QC TUSSIN DM SYRUP 53495 Appendix M Q-TAPP DM ELIXIR 12934 Appendix N Q-TUSSIN DM SYRUP 53495 Appendix M Q-TUSSIN-DM SYRUP 53495 Appendix M RESCON-DM LIQUID 93335 Appendix M RESPERAL-DM DROPS 97174 Appendix B ROBAFEN-DM CLEAR SYRUP 53495 Appendix M ROBAFEN-DM SYRUP 53495 Appendix M RYNEX DM LIQUID 26808 Appendix N SILPHEN DM COUGH SYRUP 17801 Appendix M SILTUSSIN DM COUGH SYRUP 53495 Appendix M SILTUSSIN DM DAS LIQUID 53491 Appendix M SM TUSSIN DM SYRUP 53495 Appendix M SUDATEX-DM TABLET 99175 Appendix A SU-TUSS DM ELIXIR 53558 Appendix K TL-DEX DM LIQUID 21604 Appendix L TL-HIST DM LIQUID 99356 Appendix L TRI-DEX PE LIQUID 13848 Appendix L TRIGOFEN DM DROPS 98828 Appendix F TUSSIN DM CLEAR LIQUID 53495 Appendix M TUSSIN DM LIQUID 53491 Appendix M TUSSIN DM SYRUP 53495 Appendix M VIRDEC DM DROPS 25730 Appendix F Y-COF DMX LIQUID 99356 Appendix L Z-COF 8 DM ORAL SUSPENSION 99400 Appendix L ZOTEX-12D SR TABLET 18241 Appendix Q July 18, 2012 Copyright 2012 Health Information Designs, LLC 4
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
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
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