1
Updated: February 23, 2004
Drug Name or Class
ADD/ADHD/Narcolepsy Agents
(Adderall, Adderall XR,
Concerta, Cylert, Dexadrine,
Focalin, methylphenidate,
pemoline, dextroamphetamine,
Provigil, Strattera, etc.)
ADD/ADHD/Narcolepsy Agents
(Adderall, Concerta, Cylert,
Dexadrine, Focalin,
methylphenidate, pemoline,
dextroamphetamine, Provigil,
Strattera, etc.)
Anti-Cancer Agents, Oral
(Xeloda, methotrexate,
cyclophosphamide, etoposide,
Alkeran, Myleran, Temodar)
Diagnosis
Attention Deficit Disorders (ADD); hyperkinesis
ICD-9 Code(s)
314.0; 429.82
Additional Information
Concerta is limited to age 6-12
Narcolepsy
347.0
Concerta is limited to age 6-12
Cancer
230.9-239.9
Anti-Leprotic Meds
(Lamprene, Dapsone,
Thalomid)
Leprosy
030.0-030.8; 030.9
Arava, Enbrel, Humira, Kineret,
Remicade
Rheumatoid Arthritis (RA)
714.0
This only affects Medicare/
Medicaid Recipients. Claim will
deny if one of these diagnosis
codes is present. Claim will
require TPL if diagnosis code is
missing. Claim will continue
adjudication if alternate
diagnosis code is present.
Claim will deny if one of these
diagnosis codes is present.
Claim will require PA if
diagnosis code is missing.
Claim will continue adjudication
if any other diagnosis code is
present.
Physician specialty must equal
Rheumatology or claim will
require PA.
Altinac, Avita, Retin-A
wrinkling of the skin
701.8
Axid, Pepcid, Zantac
(See H2-Antagonist)
Any diagnosis code other than
wrinkling of the skin will allow
claim adjudication. The
diagnosis code requirement is
only for Recipients age 31 and
above.
2
Updated: February 23, 2004
Drug Name or Class
Avita
Diagnosis
wrinkling of the skin
ICD-9 Code(s)
701.8
Avonex, Betaseron, Copaxone,
Rebif
Betaseron
Relapsing Multiple Sclerosis
340.0
Relapsing Multiple Sclerosis
340.0
Celebrex
Familial Adenomatous Poylposis (FAP)
211.3
Copaxone
Relapsing Multiple Sclerosis
340.0
Coreg
Congestive Heart Failure (CHF)
428.0-428.9
Daunoxome (daunorubicin
liposone)
Enbrel
Advanced HIV-related Kaposi's sarcoma
M9140/3; 176.9
Rheumatoid Arthritis (RA)
714.0
Gleevec (imatinib mesylate)
Chronic Myeloid Leukemia (CML)
H2-Antagonists (Axid, Pepcid,
Zantac)
H2-Antagonists (Axid, Pepcid,
Zantac)
H2-Antagonists (Axid, Pepcid,
Zantac)
Humira
Kineret
Additional Information
Any diagnosis code other than
wrinkling of the skin will allow
claim adjudication. The
diagnosis code requirement is
only for Recipients age 31 and
above.
Non-CHF diagnosis will require
a PA
Physician specialty must equal
Rheumatology or claim will
require PA
205.0-205.9; 207.0-207.2;
288.8
PUD
536.8; 533.0-533.9
OTC products do not require a
PA if one of these diagnoses is
listed. Rx products except Rx
cimetidine require a PA.
Zollinger-Ellison (ZE) syndrome/hypersecretory state 251.5
OTC products do not require a
PA if one of these diagnoses is
listed. Rx products except Rx
cimetidine require a PA.
Gastroesophageal Reflux Disease (GERD)
530.11, 530.81
OTC products do not require a
PA if one of these diagnoses is
listed. Rx products except Rx
cimetidine require a PA.
Rheumatoid Arthritis (RA)
714.0
Physician specialty must equal
Rheumatology or claim will
require PA.
Rheumatoid Arthritis (RA)
714.0
Physician specialty must equal
Rheumatology or claim will
require PA.
3
Updated: February 23, 2004
Drug Name or Class
Diagnosis
Multiple Sclerosis Products
Relapsing Multiple Sclerosis
(Avonex, Betaseron, Copaxone,
Rebif)
ICD-9 Code(s)
340.0
Additional Information
Immunosupressants
Transplant
(medications in the therapeutic
class Z2E, methylprednisolone,
prednisone, prednisolone)
V42.0-V42.9; 996.0996.52; 996.8
This only affects Medicare/
Medicaid Recipients. Claim will
deny if one of these diagnosis
codes is present. Claim will
require TPL if diagnosis code is
missing. Claim will continue
adjudication if alternate
diagnosis code is present.
Maximum of 14-day supply is
allowed without a PA for this
diagnosis.
Requires a physician specialty
code of Gastroenterology or
Internal Medicine or Pediatrics
with a Subspecialty in
Gastroenterolgy as well as a
diagnosis code.
Pepcid
(See H2-Antagonist)
Protonix
H. Pylori
008.43; 041.86
Protonix
GERD
530.11; 530.81
Rebif
Relapsing Multiple Sclerosis
340.0
Remicade
Rheumatoid Arthritis (RA)
714.0
Physician specialty must equal
Rheumatology or claim will
require PA.
Retin-A
wrinkling of the skin
701.8
Any diagnosis code other than
wrinkling of the skin will allow
claim adjudication. The
diagnosis code requirement is
only for Recipients age 31 and
above.
4
Updated: February 23, 2004
Drug Name or Class
Tritec
Diagnosis
H. Pylori
Tuberculosis Medications
(isoniazid, ethambutol,
pyrazinamide)
Pulmonary Tuberculosis
Vitamins, Multiple/Pregnancy &
lactation
Pregnancy; Lactation
Vitamins, Multiple/ESRD
End Stage Renal Disease (ESRD)
585.0
Vioxx
714.0; 715.0-715.9
Vitamin B12 (cyanocobalamin)
Rheymatoid Arthritis (RA); Osteoarthritis (OA);
Degenerative Joint Disease (DJD)
Malabsorption syndrome of Vitamin B12 due to
gastrectomy
Pernicious Anemia
Vitamin B12 (cyanocobalamin)
Other Vitamin B12 anemias
281.1
Vitamin B12 (cyanocobalamin)
Vitamin B12 and folate anemias
281.3
Vitamin B12 (cyanocobalamin)
Vitamin B12 deficiency
266.2
Vitamin C (ascorbic acid)
Urinary Tract Infections (UTI)
582.0-582.9; 590.00590.01; 590.9; 595.0595.2
Zantac
(See H2-Antagonist)
Zyvox (linezolid)
Any diagnosis will allow claim to adjudicate
Any diagnosis will allow
claim to adjudicate
Vitamin B12 (cyanocobalamin)
ICD-9 Code(s)
008.43; 041.86
Additional Information
Days supply must be 28 days or
less for claim to process without
a PA for this diagnosis.
10.0; 10.8-10.9; 11.0-11.2; Claim will deny if one of these
11.4; 11.8-11.9
diagnosis codes is present.
Claim will require PA if
diagnosis code is missing.
Claim will continue adjudication
if any other diagnosis code is
present.
V22.0-V22.2; V23; 611.6;
675.2; 676.4-676.6; 676.8;
676.9
Age must be greater than 60
years or claim will require PA.
579.3
281.0
Limited to a maximum of a 14day supply per dispensing