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Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Dextromethorphan Overutilization 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 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization Dextromethorphan Overutilization 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 ALLFEN DM TABLET ALL-NITE LIQUID ATUSS DS SUSPENSION BP 8 COUGH ORAL SUSPENSION BPM-PSE-DM LIQUID BROMALINE DM COLD-COUGH ELX BROMFED DM COUGH SYRUP BROTAPP DM LIQUID BROVEX PEB DM LIQUID BROVEX PSB DM LIQUID CARDEC DM DROPS CENTERGY DM PEDIATRIC DROPS CHILDREN COLD & COUGH DM ELIXI CHILDREN'S MUCINEX COUGH LIQ CHLORPHEN-PSE-DM TANNATE SUSP CORFEN-DM LIQUID COUGH & SORE THROAT LIQUID CPM-PSE DM DROPS DALLERGY DM SYRUP DAYTIME LIQUID CAPSULE DE-CHLOR DM LIQUID DECONEX DM CAPSULE DECONEX DMX TABLET DECONSAL DM TABLET CHEW DELSYM 30 MG/5 ML SUSPENSION DELSYM COUGH-COLD NIGHTIME LIQ DELSYM MULTI-SYMPTOM NIGHT LIQ DIMAPHEN DM ELIXIR 99356 23807 20556 97532 99400 99910 12934 96136 12934 18314 99910 25730 98828 26808 53497 97532 19347 20556 98115 98771 25093 13848 28369 99656 97268 17802 20556 97134 26808 Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix July 18, 2012 Copyright © 2012 Health Information Designs, LLC L A N I L K N M N K K F F N N I L N F L D L C C C I N O N 2 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization Drugs Requiring PA Label Name GCN Classification DIMETANE-DX LIQUID DONATUSSIN DM DROPS DURAFLU TABLET ENDACOF DROPS ENTRE-S SUSPENSION EXTRA ACTION COUGH SYRUP FLUTABS TABLET GUAIFENESIN DM SYRUP INDAMIX DM SUSPENSION IOPHEN DM-NR LIQUID KIDKARE COUGH & COLD LIQUID LOHIST PEB DM LIQUID LOHIST-DM SYRUP LOHIST-PSB-DM LIQUID MAPAP COLD FORMULA CAPLET MAXICHLOR DM TABLET MAXIFED DM TABLET MAXIFED DMX TABLET MAXIFLU DM TABLET MAXIPHEN DM TABLET MEDI-TUSSIN DM DIABETIC LIQ MEDI-TUSSIN DM SYRUP MUCINEX COUGH MINI-MELT PACK MUCINEX DM ER 600-30 MG TABLET MUCINEX DM ER 1,200-60 MG TAB MUCINEX FAST-MAX DM MAX LIQUID MYHIST-DM LIQUID NASOHIST DM PEDIATRIC DROPS NEO DM DROPS NEO DM SUSPENSION NEO DM SYRUP NEUTRAHIST PDX DROPS NIGHT TIME LIQUID CAPSULE NOHIST-DM LIQUID PAIN RELIEF COLD PE CAPLET PEDIATRIC COUGH-COLD LIQUID PE-HIST DM SYRUP PHENFLU DM TABLET POLY-VENT DM TABLET PROMETHAZINE-DM SYRUP PSE BROM DM SYRUP PYRIL DM SUSP 96136 26097 18533 28106 97532 53495 18533 53495 97887 53491 96138 18314 15847 99910 27135 99966 99175 53410 99237 99499 53491 53495 99068 53550 99067 53497 23797 98828 97190 97187 99305 98115 25094 19347 27199 96138 96114 99479 99657 13975 94275 27633 Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix July 18, 2012 Copyright © 2012 Health Information Designs, LLC M F A H I M A M J M N K M K D A A A A A M M E Q P N N F G I I F C L C N L A C L I L 3 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization Drugs Requiring PA Label Name GCN Classification QC DAYTIME LIQUID CAPSULE QC NIGHTTIME COUGH LIQUID QC NIGHTTIME LIQUID CAPS QC TUSSIN DM SYRUP Q-TAPP DM ELIXIR Q-TUSSIN DM SYRUP Q-TUSSIN-DM SYRUP RESCON-DM LIQUID RESPERAL-DM DROPS ROBAFEN-DM CLEAR SYRUP ROBAFEN-DM SYRUP RYNEX DM LIQUID SILPHEN DM COUGH SYRUP SILTUSSIN DM COUGH SYRUP SILTUSSIN DM DAS LIQUID SM TUSSIN DM SYRUP SUDATEX-DM TABLET SU-TUSS DM ELIXIR TL-DEX DM LIQUID TL-HIST DM LIQUID TRI-DEX PE LIQUID TRIGOFEN DM DROPS TUSSIN DM CLEAR LIQUID TUSSIN DM LIQUID TUSSIN DM SYRUP VIRDEC DM DROPS Y-COF DMX LIQUID Z-COF 8 DM ORAL SUSPENSION ZOTEX-12D SR TABLET 25093 26684 25094 53495 12934 53495 53495 93335 97174 53495 53495 26808 17801 53495 53491 53495 99175 53558 21604 99356 13848 98828 53495 53491 53495 25730 99356 99400 18241 Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix July 18, 2012 Copyright © 2012 Health Information Designs, LLC D N C M N M M M B M M N M M M M A K L L L F M M M F L L Q 4 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization Dextromethorphan Overutilization 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 Appendix A Age 12 Appendix B Appendix C Appendix D 12 12 Appendix E Appendix F Appendix G Appendix H Appendix I 12 Appendix J 12 Appendix K 12 Appendix L 12 Appendix M 12 Appendix N July 18, 2012 6-11 years years and older 2-5 years 6-11 years 6-11 years years and older 6-11 years years and older 2-5 years 6-11 years 2-5 years 6-11 years 2-5 years 6-11 years 2-5 years 6-11 years 2-5 years 6-11 years years and older 2-5 years 6-11 years years and older 2-5 years 6-11 years years and older 2-5 years 6-11 years years and older 2-5 years 6-11 years years and older 2-5 years 6-11 years Copyright © 2012 Health Information Designs, LLC Maximum Dose/Day 3 units 6 units 6 ml 6 ml 4 units 8 units 6 units 12 units 6 units 12 units 6 units 12 units 11 ml 11 ml 12 ml 12 ml 5 ml 10 ml 20 ml 5.46 ml 11 ml 22 ml 7.5 ml 15 ml 30 ml 10 ml 20 ml 40 ml 15 ml 30 ml 60 ml 30 ml 60 ml 5 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization Age and Dosing Limits Classification Appendix O Appendix P Appendix Q July 18, 2012 Age 2-5 years 6-11 years 12 years and older 6-11 years 12 years and older 6-11 years 12 years and older Copyright © 2012 Health Information Designs, LLC Maximum Dose/Day 90 ml 180 ml 180 ml 1 unit 2 units 2 units 4 units 6 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization 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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