Cough/Cold Medications

Texas Prior Authorization Program Clinical Criteria

Cough/Cold Medications

NOTE: ? Claims for cough and cold products containing acetaminophen or ibuprofen are not

covered by Texas Medicaid for ages 2 to < 6 years of age.

? Cough and cold products containing opioids are not covered by Texas Medicaid for

ages < 18. Prior authorization for these agents will not be accepted.

? Claims for cough and cold products for clients less than 2 years of age are not

covered by Texas Medicaid. Prior authorization for these agents will not be accepted.

Clinical Criteria Information Included in this Document Cough and Cold Medications (Table A ? drugs requiring prior authorization for children ages 2 to < 4 years of age) ? Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria ? Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules ? Logic diagram: a visual depiction of the clinical criteria logic ? References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section.

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Cough and Cold Medications (Table B ? drugs requiring prior authorization for children ages 2 to < 6 years of age) ? Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria ? Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules ? Logic diagram: a visual depiction of the clinical criteria logic ? References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section.

Cough and Cold Medications (Table C ? drugs requiring prior authorization for children ages 2 to < 10 years of age) ? Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria ? Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules ? Logic diagram: a visual depiction of the clinical criteria logic ? References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section.

Cough and Cold Medications (Table D ? drugs requiring prior authorization for children ages 2 to < 12 years of age) ? Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria ? Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules ? Logic diagram: a visual depiction of the clinical criteria logic ? References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section.

March 10, 2020

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Revision Notes

Added GCNs for Children's Dayclear allergy cough and Vanacof DMX to Table B, pages 8-10

March 10, 2020

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Texas Prior Authorization Program Clinical Criteria

Cough and Cold Medications

Cough and Cold Medications Table A

Drugs Requiring Prior Authorization for Children Ages 2 to < 4 Years

NOTE:

? Claims for cough and cold products containing acetaminophen or ibuprofen are not

covered by Texas Medicaid for ages 2 to < 6 years of age.

? Cough and cold products containing opioids are not covered by Texas Medicaid for

ages < 18. Prior authorization for these agents will not be accepted.

? Claims for cough and cold products for clients less than 2 years of age are not

covered by Texas Medicaid. Prior authorization for these agents will not be accepted.

? The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit formulary/formularysearch.

Table A

Drugs Requiring Prior Authorization for Children 2 to < 4 Years of Age

Label Name

GCN

ALA-HIST PE TABLET APRODINE TABLET BROTAPP LIQUID CHEST CONGESTION RELIEF PE CHEST CONGESTION RELIEF TABLET CHL MUCINEX CHEST CONGEST LIQ CHLD MUCINEX STUFFY NOSE-COLD CHLO TUSS LIQUID COUGH SYRUP 200 MG/10 ML DECONEX IR TABLET DIMAPHEN ELIXIR ED BRON GP LIQUID ED-A-HIST PSE TABLET ED CHLORPED D PEDIATRIC DROPS GUAIFENESIN 100 MG/5 ML SYRUP HISTEX-PE SYRUP IOPHEN NR LIQUID KID'S MUCINEX MINI-MELTS PACK LODRANE D CAPSULE LORTUSS LQ LIQUID MAXIPHEN TABLET

28379 96445 12933 97358 18906 02512 99069 35393 02512 42022 27207 54250 96445 30033 02512 29581 02512 97123 30766 29564 97358

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Texas Prior Authorization Program Clinical Criteria

Cough and Cold Medications

Table A

Drugs Requiring Prior Authorization for Children 2 to < 4 Years of Age

Label Name

GCN

MUCUS RELIEF 400 MG TABLET MUCUS RELIEF SINUS TABLET NOSE DROPS ORGAN-I NR 200 MG TABLET POLY-HIST PD LIQUID POLY-VENT IR TABLET PROMETHAZINE VC SYRUP Q-TUSSIN 100 MG/5 ML SOLUTION RESCON-GG LIQUID RESPAIRE-30 CAPSULE ROBAFEN 100 MG/5 ML SYRUP RU-HIST D 10-4 MG TABLET RYNEX PE LIQUID RYNEX PSE LIQUID SILTUSSIN SA 100 MG/5 ML SYR STAHIST AD LIQUID STAHIST AD TABLET TUSSIN 100 MG/5 ML SYRUP

18906 97358 34186 02482 34839 34787 13977 02512 54250 13255 02512 96609 27207 12933 02512 31771 31036 02512

March 10, 2020

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Texas Prior Authorization Program Clinical Criteria

Cough and Cold Medications

Cough and Cold Medications Table A

Clinical Criteria Logic

1. Is the client greater than or equal to () 2 years and less than ( ................
................

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