Apple Health (Medicaid): Provider Alert
Effective for claims with dates of service on and after June 1, 2017, Washington Apple Health (Medicaid), administered by the Health Care Authority, will update the Expedited Authorization (EA) list as follows:
|
Product
|
Code
|
Criteria
|
|
Aciphex®
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
bupropion HCl
|
072
|
Client is receiving smoking (tobacco) cessation counseling.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
Chantix®
|
072
|
Client is receiving smoking (tobacco) cessation counseling.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
Dexilant®
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
esomeprazole magnesium
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
esomeprazole strontium
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
gabapentin
|
035
|
Removed
|
|
036
|
Removed
|
|
063
|
Removed
|
|
lansoprazole
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Neurontin®
|
035
|
Removed
|
|
036
|
Removed
|
|
063
|
Removed
|
|
Nexium®
Nexium® granules
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Nicoderm®
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
Nicorette®
nicotine gum/ lozenge/patches
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
nicotine
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
Nicotrol®
|
072
|
Client is receiving smoking (tobacco) cessation counseling.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
omeprazole OTC/RX
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
omeprazole-sodium bicarbonate
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
pantoprazole sodium
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Prevacid®
Prevacid® SoluTab™
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Prilosec OTC®
Prilosec® Rx
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Protonix®
Protonix Pack®
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
rabeprazole sodium
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Riomet®
|
050
|
Removed.
|
|
086
|
Inability to swallow oral tablets or capsules.
|
|
Zegerid®
|
079
|
Diagnosis of H. pylori with ulcer present. Limited to 28 units for 14 days for initial fill.
|
|
Zyban®
|
072
|
Client is receiving smoking (tobacco) cessation counseling.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
073
|
Client is:
a) Between the ages of 10 and 40
b) Pregnant, and
c) Receiving smoking (tobacco) cessation counseling from their prescriber, qualified practitioner, or the Quitline.
Washington State Tobacco Quitline phone number: 1-800-784-8669.
|
|
