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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