Drugs requiring transmission of a diagnosis code

Revised August 2016

The purpose of this information is to ensure cost minimization and appropriate use.

You must include the most current ICD diagnosis code on all claims for certain drugs. Refer to the medication and covered diagnoses table. A diagnosis code is required to:

• Ensure that a drug is being used appropriately, without restricting its access through prior authorization (PA)
• Ensure that the most cost effective dosage form is used

Medication and covered diagnosis

Medication names	Diagnosis
Stimulants, including:  methylphenidate dexmethylphenidate dextroamphetamine lisdexamfetamine methamphetamine (Adderall) mixed amphetamines	Autism ADD without hyperactivity ADD with hyperactivity Hyperkinesis with developmental delay Hyperkinetic conduct disorder Other hyperkinetic syndrome Narcolepsy Major depressive disorder, single Major depressive disorder, recurrent episode Unspecified episodic mood disorder; Mood swings Other nonorganic psychoses Depressive disorder, not elsewhere classified Multiple sclerosis
Strattera (atomoxetine)	ADD without hyperactivity ADD with hyperactivity Hyperkinesis with developmental delay  Hyperkinetic conduct disorder Other hyperkinetic syndrome
Cipro XR (brand and generic) 500 mg, 1000 mg	Cipro XR 500 mg Covered only for treatment of uncomplicated UTI (acute cystitis) (maximum quantity is 3) Cipro XR 1000 mg Covered only for the treatment of complicated UTI or acute uncomplicated pyleonephrititis (maximum quantity is 14)
Abilify Rapid tabs Invega Sustenna clonazepam orally disintegrating tablet Niravam (alprazolam) Remeron (mirtazapine) Soltabs Zyprexa Relprevv Zyprexa Zydis Risperdal-M Parcopa (brand and generic)	History of non-compliance Difficulty swallowing (dysphagia)