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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 Updated GCNs and dosing guidelines March 3, 2016 Copyright © 2016 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 AP-HIST DM LIQUID ALLFEN DM TABLET BROMFED DM COUGH SYRUP BROMPHENIR-PSEUDOEPHEN-DM SYR BROTAPP DM LIQUID CHILD DELSYM COUGH+CHEST DM LQ CHILDREN COLD & COUGH DM ELIXI CHILDREN'S MUCINEX COUGH LIQ CHILD MUCINEX CONGEST-COUGH LIQ CHILD MUCINEX MULTI-SYMPTOM LIQ COUGH DM ER 30MG/5ML SUSPENSION COUGH & SORE THROAT LIQUID DAYTIME COLD-FLU RLF SOFTGEL DECONEX DMX TABLET DELSYM 30 MG/5 ML SUSPENSION DELSYM COUGH+CHEST CNGST DM LQ DEXTROMETHORPHAN ER 30MG/5ML DIMAPHEN DM ELIXIR DURAFLU TABLET ED-A-HIST DM LIQUID ENDACOF-DM LIQUID EXTRA ACTION COUGH SYRUP HISTEX-DM SYRUP IOPHEN DM-NR LIQUID KIDKARE COUGH & COLD LIQUID LOHIST PEB DM LIQUID LOHIST-DM SYRUP LORTUSS DM LIQUID 99356 99356 23807 96136 96136 12934 53497 26808 53497 28875 28875 17802 20556 25093 99656 17802 53497 17802 26808 18533 19347 26808 53495 36311 53491 96138 18314 15847 39565 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 March 3, 2016 Copyright © 2016 Health Information Designs, LLC L L A M M N N N N T T I N D C I N I N A L N M K M N K M L 2 Texas Prior Authorization Program Clinical Edits Dextromethorphan Overutilization Drugs Requiring PA Label Name GCN Classification M-END DMX LIQUID MAXIPHEN DM TABLET MAPAP COLD FORMULA CAPLET MUCINEX COUGH MINI-MELT PACK MUCINEX DM ER 600-30 MG TABLET MUCINEX DM ER 1,200-60 MG TAB MUCINEX FAST-MAX CONGEST-COUGH MUCINEX FAST-MAX DM MAX LIQUID NIGHT TIME COLD-FLU RLF SFTGL NOHIST-DM LIQUID PEDIATRIC COUGH-COLD LIQUID POLY-HIST DM LIQUID POLY-VENT DM TABLET PROMETHAZINE-DM SYRUP Q-TUSSIN DM SYRUP QC TUSSIN DM SYRUP RESCON-DM LIQUID ROBAFEN CF LIQUID ROBAFEN-DM SYRUP ROBAFEN DM COUGH LIQUID RYNEX DM LIQUID SILTUSSIN DM COUGH SYRUP SILTUSSIN DM DAS LIQUID SM TUSSIN DM SYRUP TUSSIN DM CLEAR LIQUID TUSSIN DM LIQUID TUSSIN DM SYRUP VANACOF DM LIQUID VIRDEC DM DROPS 30801 99499 27135 99068 53550 99067 28875 53497 25094 19347 96138 34835 34799 13975 53495 53495 93335 53090 53495 53491 26808 53495 53491 53495 53495 53491 53495 34782 25730 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 March 3, 2016 Copyright © 2016 Health Information Designs, LLC M A D E Q P T N C L N M C L M M M M M M N M M M M M M R E 3 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 Appendix C Appendix D Age Maximum Dose/Day 6-11 years 12 years and older 6-11 years 12 years and older 6-11 years 12 years and older 3 6 4 8 6 12 units units units units units units Appendix E 6-11 years 12 units Appendix I 4-5 years 6-11 years 12 years and older 5 ml 10 ml 20 ml 6-11 years 15 ml 12 years and older 6-11 years 12 years and older 30 ml 20 ml 40 ml 6-11 years 30 ml 12 years and older 60 ml 6-11 years 60 ml 6-11 years 12 years and older 6-11 years 12 years and older 6-11 years 12 years and older 6-11 years 12 years and older 1 unit 2 units 2 units 4 units 50 ml 100 ml 60 ml 120 ml Appendix K Appendix L Appendix M Appendix N Appendix P Appendix Q Appendix R Appendix T March 3, 2016 Copyright © 2016 Health Information Designs, LLC 4 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 02/16/2016 Updated GCNS and dosing guidelines March 3, 2016 Copyright © 2016 Health Information Designs, LLC 5
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