PACE

 PROVIDER BULLETIN

October 8, 2004

DUR Edits

Effective October  18,  2004,  several new initial therapy , appropriate diagnosis , maximum quantity, initial quantity, maximum duration, maximum quantity and duplicate therapy criteria will be added to the PACE ProDUR Program.  The criteria is as follows:

 

Drug Name

Initial

Therapy

Approved

Diagnosis

Maximum

Quantity

Initial Qty.

Maximum

Duration

Duplicate

Therapy

 

 

 

 

 

 

 

Xanax

XR®

 

Approved only for Panic Disorder

”CH” –Call Help Desk response returned.

 

 

 

 

 

 

 

 

 

 

 

Duragesic®

Patches

Conversion with an opiate is required prior to reimbursement of a 25mcg patch.

*DUR Conflict code: PP –“Plan Protocol” response returned.

 

10 patches will be permitted every 30 days. An additional 10 patches will be permitted if dose is increased

 

 

 

 

 

 

 

 

 

 

Actiq®

 

Approved only for diagnosis of Cancer.

”CH” –Call Help Desk response returned.

A maximum of 48 units will be reimbursed every 30 days.

Initial quantity cannot exceed 6 units

 

 

Duragesic®, acetominophen w/hydrocodone

Oxycontin®, acetominophen

/oxycodone

 

 

 

 

Therapy beyond 180 days will require diagnostic information from the physician. 

 

 

 

 

 

 

 

 

MS Contin®

Prior conversion with an opiate must be shown before approval of 200 mg.

*DUR Conflict code: PP –“Plan Protocol” response returned.

 

 

 

 

 

 

 

 

 

 

 

 

Duragesic®,

MS Contin®, Oramorph®, Oxycontin®, Kadian

 

 

 

 

 

Duplicate Therapy edit will be applied.

 

Providers are encouraged to examine their DUR response for additional information.

Note: PP—“Plan Protocol” may be over-ridden based on additional information from provider.

 

Questions may be directed to PACE ProDUR operators at 1-800-835-4080.

PPB-04-016