Download Cough and Cold

TEXAS MEDICAID
Clinical Edit Prior Authorization
Cough and Cold
Table D (Narcotic-containing products)
STEP 1: CLEARLY PRINT AND COMPLETE TO EXPEDITE PROCESSING
Date:
Prescriber First & Last Name:
Patient First & Last Name:
Prescriber NPI:
Patient Address:
Prescriber Address:
Patient ID:
Prescriber Phone:
Patient Date of Birth:
Prescriber Fax:
Medication Requested (Name):
Quantity Requested:
Dose Requested:
Dosing Instructions:
Preferred Drug
Non-Preferred Drug *(Formulary available at www.txvendordrug.com)
*Please finish completing this section only if medication requested is Non-Preferred*
Approval of Non-Preferred Drugs requires:
Allergic Reactions to Preferred Drugs
OR
OR
Contraindication to Preferred Drugs
Treatment failure with Preferred Drugs
If applicable, list Preferred Drug List (PDL) alternatives tried and failed:
_______________________________________________________________________________
_______________________________________________________________________________
STEP 2: COMPLETE REQUIRED CRITERIA
Indicate Primary Diagnosis: __________________________________ ICD-10 Code: __________
Rev. 06/02/2017
Version 1.4
1. Is the client greater than or equal to (≥) 6 years* and less than (<) 12 years of age?
Yes (Deny)
No (Approve 30 days)
* Claims for cough and cold products for clients less than 2 years of age are not covered by
Texas Medicaid. Claims for cough and cold products containing acetaminophen, ibuprofen, or
narcotics such as codeine and hydrocodone are also not covered for clients less than 6 years of
age. Prior authorization for these agents and age groups will not be accepted.
STEP 3: SIGN AND FAX TO: NAVITUS PRIOR AUTHORIZATION AT: 855-668-8553
Prescriber Signature: _____________________________________________ Date: ______________
If criteria not met, submit chart documentation with form citing complex medical circumstances.
For questions, please call Navitus Customer Care at 1-877-908-6023.
Rev. 06/02/2017
Version 1.4
Table D
Label Name
GCN
CHERATUSSIN AC SYRUP
CHERATUSSIN DAC SYRUP
CODEINE-GUAIFEN 10-100 MG/5 ML
FLOWTUSS 2.5-200 MG/5 ML SOLN
GUAIATUSSIN AC LIQUID
GUAIFENESIN AC COUGH SYRUP
GUAIFENESIN-CODEINE SYRUP
HYCOFENIX 2.5-30-200 MG/5 ML
HYDROCOD-CPM-PSEUDOEP 5-4-60/5ML
HYDROCOD-HOMATROP 5-1.5 MG TAB
HYDROCODONE-CHLORPHEN ER SUSP
HYDROCODONE-HOMATROPINE SYRUP
HYDROMET SYRUP
IOPHEN-C NR LIQUID
LORTUSS EX LIQUID
M-END MAX D LIQUID
NINJACOF-XG LIQUID
PHENYLHISTINE DH LIQUID
PROMETHAZINE-PE-CODEINE SYRUP
PROMETHAZINE VC-CODEINE SYRUP
PROMETHAZINE-CODEINE SYRUP
REZIRA SOLUTION
TUSSIONEX PENNKINETIC SUSP
VIRTUSSIN AC LIQUID
ZUTRIPRO SOLUTION
91713
54670
91713
37679
91713
91713
91713
38666
30047
96041
13974
13973
13973
91713
54670
30764
30677
14266
13978
13978
13971
92058
13974
91713
30047
Rev. 06/02/2017
Version 1.4