Download Cough and Cold Age 6-12 Prior Authorization Form Addendum

Texas Standard Prior Authorization Form Addendum
Molina Healthcare of Texas
Cough/Cold Medications
(Children ≥ 6 to < 12 years of age)
This fax machine is located in a secure location as required by HIPAA Regulations. Complete / Review information,
sign, and date. Fax signed forms to Molina Pharmacy Prior Authorization Department at 1-888-487-9251. Please contact
Molina Pharmacy Prior Authorization Department at 1-855-322-4080 with questions regarding the prior authorization
process. When conditions are met, we will authorize the coverage of Cough/Cold Medications (Children ≥ 6 to < 12 years
of age).
Drug Name (select from list of drugs shown / provide drug information)
Patient Information
Patient Name:
Patient ID:
Patient DOB:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis:
ICD Code:
Directions for administration:
Please Note:
Claims for cough and cold products containing acetaminophen, ibuprofen, or narcotics such as codeine and
hydrocodone are not covered by Texas Medicaid for ages ≥ 2 to < 6 years of age. Prior authorization for these agents
will not be accepted.
Claims for cough and cold products for patients less than 2 years of age are not covered by Texas Medicaid. Prior
authorization for these agents will not be accepted.
Please circle the appropriate answer for each question.
1.
Is the patient greater than or equal to (≥) 6 years and less than (<) 12 years of age?
Y
N
Y
N
If the answer to this question is yes, deny.
If the answer to this question is no, go to question 2.
2.
Is this request for a non-preferred drug?
The Texas Medicaid Preferred Drug List can be found at www.txvendordrug.com
If the answer to this question is yes, go to question 3.
If the answer to this question is no, approved 30 days.
MHTPA011516-5
3.
Has the patient had a treatment failure with a preferred drug within any subclass or a
contraindication or allergic reaction to any preferred drugs?
Y
N
If yes, please list which drug, dates tried, and describe treatment failure, contraindication or allergy.
________________________________________________________________________________
If no, denied.
Drugs Requiring Prior Authorization for Children ≥ 6 to < 12 Years of Age
Drug Name
M-END MAX D LIQUID
CHERATUSSIN AC SYRUP
CHERATUSSIN DAC SYRUP
M-END WC LIQUID
CODEINE-GUAIFEN 10-100 MG/5 ML
NINJACOF-XG LIQUID
ENDACOF-C LIQUID
PHENYLHISTINE DH LIQUID
GUAIATUSSIN AC LIQUID
POLY-TUSSIN D LIQUID
POLY-TUSSIN LIQUID
GUAIFENESIN AC COUGH SYRUP
GUAIFENESIN-CODEINE SYRUP
PRO-CLEAR AC SYRUP
HYDROCOD-CPM-PSEUDOEP 5-4-60/5ML
PROMETHAZINE VC-CODEINE SYRUP
HYDROCOD-HOMATROP 5-1.5 MG TAB
PROMETHAZINE-CODEINE SYRUP
HYDROCODONE-CHLORPHEN ER SUSP
REZIRA SOLUTION
HYDROCODONE-HOMATROPINE SYRUP
TUSSIONEX PENNKINETIC SUSP
HYDROMET SYRUP
VIRTUSSIN AC LIQUID
VITUZ SOLUTION
IOPHEN-C NR LIQUID
LORTUSS EX LIQUID
ZUTRIPRO SOLUTION
Comments:
I affirm that the information given on this form is true and accurate as of this date.
_____________________________________________________
Prescriber (or Authorized) Signature
MHTPA011516-5
________________________________
Date