Medical Access Program Provider Handbook TABLE OF CONTENTS

Transcription

Medical Access Program
Provider Handbook
May 2015
with revisions
Provider Handbook
TABLE OF CONTENTS
Section 1:
INTRODUCTION
Section 2:
ENROLLMENT AND DISCHARGE
Section 3:
COVERAGE VERIFICATION
Section 4:
CO-PAYMENTS, GROUPS AND PLANS
Section 5:
SERVICES AND AUTHORIZATIONS
Section 6:
MEDICAL MANAGEMENT
Section 7:
CONTRACT PROVIDERS
Section 8:
SPECIALTY CARE Section
Section 9:
PHARMACY SERVICES
Section 10: CLAIMS
Section 11: FREQUENTLY ASKED QUESTIONS
Section 12: QUICK REFERENCE: CONTACTS AND HELPFUL NUMBERS
Section 13: COMMUNITY CARE — WOMEN’S HEALTH CENTER
Provider Handbook
1.
INTRODUCTION
Disclaimer
Information in the Provider Handbook is current as of the date
of release with revisions. All efforts are made to maintain the
accuracy of the information found within.
It is the responsibility of the Provider to verify that the
most current revision documents of the Handbook are used
for the provision of services
Provider Handbook
2. ENROLLMENT
Provider Handbook
ENROLLMENT
ELIGIBILITY OFFICES
COVERAGE
MAP RENEWAL AND/OR EXPIRED COVERAGE
CHANGE OF ADDRESS
LOST MAP ID CARD
CUSTOMER SERVICE CALL CENTER
DISCHARGE FROM PRACTICE
Provider Handbook
ENROLLMENT
ELIGIBILITY OFFICES
Central/East Austin Eligibility
Office
Northeast Austin Eligibility Office
South Austin-South Eligibility Office
North Rural Community CenterPflugerville
South Rural Community CenterDel Valle
1213 N I.H.35 Suite 100
Austin, Texas 78702
Telephone: 512-978-8130
6633 HWY 290 East Suite 310
Austin, Texas 78753
Telephone: 512-978-8130
2028 E Ben White Blvd Suite 115
Austin, Texas 78741
Telephone: 512-978-8130
15822 Foothill Farms Loop, Building D
Pflugerville, Texas 78660
Telephone: 512-978-8130
3518 FM 973
Del Valle, Texas 78617
Telephone: 512-978-8130
Enrollment
Page 1 of 3
Revised 09/01/2013
Provider Handbook
COVERAGE
MAP enrollees are given a pink identification card, which states the
effective and expiration dates of coverage, co-payments, and other
important information.
The length of issuance for MAP coverage may range from one month to
one year and is dependent on the enrollee’s circumstances as determined
during the enrollment process.
The MAP card does not guarantee coverage.
Services, supplies, or equipment provided without active MAP coverage
will not be reimbursed.
 To verify coverage, visit the Provider Self Service website at
www.medicaider.com/medicaid/manager/start.asp.
MAP RENEWAL and/or EXPIRED COVERAGE
Enrollees are encouraged to call our Customer Service Call Center at
(512) 978-8130 or visit an eligibility office two to three (2-3) weeks in
advance of her or his MAP expiration date to schedule an
enrollment/eligibility appointment.
Enrollment
Page 2 of 3
Revised 09/01/2013
Provider Handbook
CHANGE OF ADDRESS
An enrollee should be referred to the Customer Service Call Center at
(512) 978-8130 or to the eligibility office nearest her/his home to report a
change of address.
LOST MAP ID CARD
An enrollee should be referred to the Customer Service Call Center at (512)
978-8130 or to the eligibility office nearest her/his home to obtain a
replacement MAP identification card.
CUSTOMER SERVICE PHONE LINE
The Medical Access Program Customer Service Call Center is available to
enrollees and providers for benefit information, general information,
setting eligibility appointments or reporting changes. The phone number
is (512) 978-8130.
Enrollment
Page 3 of 3
Revised 09/01/2013
Provider Practice Discharge Notification Process
There are situations in which a Provider may discharge a MAP Enrollee from
their medical practice. The procedure for communication to the MAP
Enrollee, Sendero Health Plans, and MAP Eligibility Services once a
notification has been received is as follows:
1. The Provider’s notification letter of the discharge from the practice
to the MAP Enrollee will also include a letter from MAP Eligibility
Services explaining where enrollee may receive services (see
attachment).
2. The Provider will fax (512) 901-9724 the notification of the discharge
from practice to the Sendero’s Quality Improvement (QI) Manager.
3. The Sendero QI manager or designee will send notification to the
MAP Service Delivery Coordinator or designee and to other
designated departments in Sendero.
Dear MAP Enrollee:
The Applicant Responsibilities you signed during your MAP enrollment
process states that the Medical Access Program will only reimburse care
received through contracted providers. Please be advised that at this
time, due to your termination as a patient with your current primary
clinic, your only option for primary care is through the urgent care centers
contracted by Central Health.
If you need primary care services you may call NextCare Urgent Care
Centers at 1-888-381-4858 to find a location.
In an emergency, you may use the emergency room at the University
Medical Center at Brackenridge located at 601 E 15th Street, Austin, Texas.
For additional information regarding your MAP benefits, call the Customer
Service Call Center at (512) 978-8130.
Thank you,
MAP Eligibility Services
Provider Handbook
3. COVERAGE VERIFICATION
Provider Handbook
How to read a MAP identification card
 See “How to read a MAP Identification Card.”
How to check eligibility coverage “on-line”
 See “Provider Self Service Registration and Instructions.”
Coverage Verification
Page 1 of 1
Revised 09/01/2013
Provider Handbook
The MAP card does not guarantee coverage. To verify coverage, visit the Provider
Self Service at www.medicaider.com/medicaid/manager/start.asp.
1
2
4
6
8
3
5
7
9
10
3
7
9
MAP Card Legend
1.
ID#: Enrollee’s Master Record Number. In this case, the MR# is 474238.
2.
Group: This is the Group Identifier for the enrollee’s level of coverage issued.
3.
Plan: This is the enrollee’s coverage plan type.
4.
EFF: This is the effective date of the enrollee’s coverage. The format is
MM/DD/YYYY.
Page 1 of 2
12/2013
Provider Handbook
5.
EXP: This is the expiration date of the enrollee’s coverage. The format is
MM/DD/YYYY.
6.
This is where you will see the enrollee’s name. The format is first name, middle
name, last name.
7.
DOB: This is where you will see the enrollee’s date of birth. The format is
M/D/YYYY.
8.
CO-PAY: OP ($1o) IP ($3o) ER ($25): This is the co-pay amounts to be requested
from the enrollee at time of service.
In some exceptional cases an enrollee’s co-pay may be zero ($0). These cases
will be documented at the time of an enrollment/eligibility interview and the
zero co-pay printed on the ID card.
For further information regarding co-payments, groups, and plans see section 4.
9.
Dental: This is the co-pay amount to be requested from the enrollee at time of
service.
10.
RX: This is the co-pay amount to be requested from the enrollee per eligible
prescription.
In some exceptional cases an enrollee’s co-pay may be zero ($0). These cases
will be documented at the time of an enrollment/eligibility interview and the
zero co-pay printed on the ID card.
Page 2 of 2
12/2013
Central Health
Provider Self-Service
Registration & Instructions
SEPTEMBER
2013
Provider Self-Service Registration
Section I
Registering For Provider Self Service
STEP 1
In order to use the Provider Self-Service Website, you must first register on the Provider Eligibility
Registration webpage. Generally, turn around time for the registration process is three business days.
Using the most current version of Internet Explorer web browser, go to
www.medicalaccessprogram.net. In order to access the website and its range of functions, you must
use Internet Explorer version 7.0 or higher.
Once you are on the main page for the Medical Access Program website, you must choose the tab
labeled For Providers.
STEP 2
On the For Providers page, you will see a link on Online Agreement and fill out the preregistration form. Click on the link, this will lead to the Provider Eligibility Registration page.
STEP 3
This is where the Provider Eligibility Self- Service Registration is located. Please read the Online
Access Agreement and scroll to the bottom of the page for registration.
Step 4
Please enter the requested information in the appropriate boxes. One the information is entered
completely, please choose the Submit button found at the bottom of the webpage.
Step 5
Please note once you submit your information, you will receive an email indicating there was
a successful submission.
You should receive two emails within three business days of a successful submission.
One email will include:
Your user name
The CHASSIS Software Web Address
Technical Support
Provider Self-Service Quick Reminders
Second email will include:
Your temporary password
A reminder to change the temporary password upon first use
Provider Handbook
4. CO-PAYMENTS, GROUPS, AND
PLANS
Provider Handbook
CO-PAYMENTS, GROUPS and PLANS
The MAP card does not guarantee coverage. To verify coverage, visit the Provider
Self Service website at www.medicaider.com/medicaid/manager/start.asp.
GROUP
CBRACKFQ
CBRACKFQ
PLAN
CBRACKFQ
CPENDSSI
Out-patient Contract
PCPs Contract
specialty
providers
Urgent care
In-patient
Emergency Room
Dental office visit
Partial Dentures
Full Dentures
$1o co-pay or
$o co-pay if noted on MAP card
$1o co-pay or
$3o co-pay or
$25 co-pay or
$1o co-pay or
$35 per partial or
$5o per plate or
$3o co-pay or
$25 co-pay or
$1o co-pay or
$35 per partial or
$5o per plate or
Pharmacy
Formulary
Non-Formulary
$7 co-pay for 1-3o day supply or
$7 co-pay for 1-3o day supply or
$20 co-pay for 31-9o* day supply or $20 co-pay for 31-9o* day supply or
*90 day supply on selected drugs
only
*90 day supply on selected drugs
only
$1o co-pay or
$1o co-pay or
Co-payments, Groups and Plans
Page 1 of 1
Revised o1/11/2o12
Provider Handbook
5. SERVICES AND AUTHORIZATIONS
Services
Services and Authorizations Matrix
Referral Authorizations
Central Health Authorization Request Form
Seton Health Plan Pre-Certification Form
Seton Health Plan Polysomnography — Sleep Study
Authorization Form
Seton Health Plan Coverage Guidelines for Varicose Vein
Referral
MAP Exclusions
Service Authorization Matrix
Revised 09/15/2011
Services
Central Health arranges for healthcare services for Travis County residents
who are not eligible for other private or public insurance programs. To ensure
a complement of services, Central Health continues to evaluate services for
MAP enrollees.
Through contractual agreements, the Medical Access Program (MAP)
provides access to health care through networks of established providers.
CENTRAL HEALTH-MAP is responsible for primary care services, dental
services, and selected specialty services. Seton Health Plan is responsible for
hospital-based and specialty, diagnostic, and durable medical equipment
services.
 See document entitled “Services and Authorizations Matrix.”
Referral Authorizations
Referral authorization is the process used to authorize designated medically
necessary services. The majority of services do not require authorization.
The primary care office submits the referral authorization request, which
provides the medical information related to services requested.
The request is reviewed, and is authorized (approved) or denied. An
authorization number only is issued when a request is authorized.
 CENTRAL HEALTH MAP: See CENTRAL HEALTH document entitled
“Authorization Request Form.”
 Seton Health Plan (SHP): See Seton Health Plan documents entitled
D “Pre-Certification Form”
D “Polysomnography — Sleep Study Authorization Form”
D “Varicose Vein Referral (Coverage Guidelines)”
Services and Authorizations
Page 1 of 2
Revised 09/15/2011
MAP Exclusions
 See document with MAP Exclusions.
Services and Authorizations
Page 2 of 2
Revised 09/15/2011
Service and Authorization Matrix
Services
AMBULANCE
Emergency, ground
Non-emergency, ground
Non Emergent TransportationI Air Ambulance
ANGIOGRAPHY I VENOGRAPHY, non-cardiac and cardiac
BLOOD AND BLOOD PRODUCTS, outpatient
Transfusion
CARDIAC REHABILITATION
Outpatient
Home health
CYBERKNIFE
CHEMOTHERAPY - ONCOLOGY
Outpatient pharmaceuticals
Home health pharmaceuticals
DENTAL SERVICES
Dental & Orthognathic services
Oral Surgery I Orthognathic
Dental Trauma
Dentures
DURABLE MEDICAL EQUIPMENT, subject to plan limitations
Apnea monitor
Bedside commode
Bili lights (phototherapy)
BIPAP
Blood glucose monitor with voice synthesizer
CPAP
CPM; dynamic splinting; passive motion device
Enteral therapy, supplies and formula
Feeding pump (enteral therapy)
Gastric suction pump
Hospital beds and accessories
Humidifier, with positive airway pressure device
Humidifiers I compressors for use with IPPB
Insulin pump
Insulin pump supplies
Joint motion rehab system (CPM)
Oxygen and related respiratory equipment
Patient lifts
PoweredINonpowered overlay for mattress
Pressure-relief pads, alternating; air; water mattress
Pulse oximeter
Safety enclosure frameIcanopy for use with hospital bed
Suction machine
TENS; neuromuscular and bone growth stimulators
Wheelchairs
Wound vac
Durable medical equipment not listed
ENDOSCOPIC I COLONOSCOPY STUDIES
Responsible Entity
CH MAP
CH MAP
A = Authorization Required from Responsible Entity
A
A
SHP
SHP
SHP
SHP
CH MAP
A
SHP
SHP
CH
CH
CH
CH
MAP
MAP
MAP
MAP
CH MAP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
CH MAP
SHP
SHP
SHP
SHP
CH MAP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
Required after 12 visits
Consultation, and followup visit authorizatinon,
treatment provided by charity two per quarter
A
A
A
SHP
SHP
SHP
SHP
EPIDURAL STERIOD INJECTION
A
A
if referred from network provider
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
Seton PT department
Only short term for reduction of inflammation for pain
management or treatments which address the cause
of the pain and are expected to result in resolution of
pain will be considered, with proper documentation of
need.
HEALTH EDUCATION
Diabetic Health Education
CH-Primary
Care
Providers
HOME HEALTH SERVICES
Infusion therapy
Drug delivery, administration, supplies, and appropriate training
Nursing assessment and care
Speech therapy
Physical I occupational therapy
Skilled Nursing Services
HOSPITALIZATION
INJECTIBLE DRUGS NOT COVERED BY PHARMACY BENEFIT
Injectible Drugs Seton
Injectible Drugs contracted provider
HYPERBARIC
LITHOTRIPSY (ESWL)
MAP-Outpatient Diabetic education and nutrition
responsibity of MAP contracted primary care
providers
SHP
SHP
SHP
SHP
SHP
SHP
SHP
A
A
A
A
A
A
A
SHP
A
CH-MAP
A
SHP
SHP
Seton Facility
Use MAP Authorization form for Contracted
provider
A
A
Page 1 of 2
Revised 09/15/2011
Services
MYELOGRAM
NUCLEAR MEDICINE DIAGNOSTICS
OPHTHALMOLOGY SERVICES
Intraocular lens (incident to cataract ! corneal surgery)
Medically necessary ophthalmology care (including YAG, retinal
procedures, etc.)
Diabetic retinal screening
ORTHOTICS
Custom orthotics
Splints and braces
PHYSICAL, OCCUPATIONAL, SPEECH AND OTHER REHAB THERAPY
Outpatient
Responsible Entity
SHP
SHP
Outpatient
Home sleep studies
SPECIALTY CARE
In-network
Out-of-network (specialties not provided at UMCB Specialty Care Clinic
such as neurosurgery)
Laboratory
VARICOSE VEIN TREATMENT
Refer to SHP Coverage Guidelines on the following page.
A
SHP
A
Covered annually
CH-MAP
SHP
A
A
SHP
A
SHP
SHP
SHP
Home health
PODIATRY SERVICES
RADIATION TREATMENT I THERAPY
Professional
Outpatient
RADIOLOGY I IMAGING, including but not limited to
Barium enema
Bone density study
Cardiac Stress
CT scan
CT chest & cardiac angiography
IVP (intravenous pyelogram)
Mammogram
Adenosine stress test
Bone scan
Perfusion studies
Persantine stress test
Thallium stress test
Thyroid scan ! uptake
Other NM not listed
MRA
MRI
MRI - with anesthesia
PET scan
Upper GI
Imaging services not listed
RECUPERATIVE CARE PROGRAM
RESPIRATORY THERAPY
Outpatient
Home health
SLEEP STUDY
SHP
CH-MAP
Wound care
PROSTHETICS
A = Authorization Required from Responsible Entity
A
A
CH MAP
Required after 8 visits
No authorization required if done in Seton
network
A
A
Covered benefit if there is no other funding
source
CH MAP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
SHP
CH MAP
A
A
A
A
A
A
A
A
A
A
A
A
A
SHP
SHP
A
SHP
A
SHP
A
Homeless only
Use SHP Sleep Study Authorization Form
located on the following page
SHP
SHP
A
SHP
SHP
A
Page 1 of 2
Revised 09/15/2011
Referral Type
☐ Routine (Process w/in 2 business days)
☐ Urgent (Process w/in 1 business day)
Medical Access Program (MAP)
AUTHORIZATION REQUEST FORM
PATIENT INFORMATION:
DATE:
PATIENT NAME:
DOB:
MAP ID#:
REFERRAL FROM:
PHYSICIAN:
PHONE/FAX:
CONTACT PERSON:
PCP IF NOT REFERRING PHYSICIAN:
REFERRAL TO/FOR:
MEDICAL INFORMATION:
DIAGNOSIS:
CODE:
REASON FOR REFERRAL:
UM INFORMATION:
AUTHORIZATION NUMBER:
AUTH.
DATE:
EXP.
DATE:
NO. OF VISITS
APPROVED:
COMMENTS:
AUTHORIZATION IS NOT A GUARANTEE THAT SERVICES WILL BE COVERED OR THAT PAYMENT WILL BE MADE. ALL MEDICAL SERVICES
RENDERED ARE SUBJECT TO CLAIMS REVIEW, WHICH INCLUDES BUT IS NOT LIMITED TO DETERMINATION OF ELIGIBILITY IN ACCORDANCE
WITH THE TERMS OF THE MEMBERS BENEFIT PLAN, ANY DEDUCTIBLES, CO-PAYMENTS AND CUSTOMARY CHARGES AND POLICY
MAXIMUMS.
NOTICE OF CONFIDENTIALITY: THE INFORMATION CONTAINED IN THIS FACSMILE (FAX) IS PRIVILEGED AND CONDFIDENTIAL. IT IS
INTENDED FOR THE INDIVIDUAL ENTITY INDICATED ON THIS REFERRAL FORM. YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION,
DISTRIBUTION, COPYING, OR OTHER USE OF THIS INFORMATION BY ANYONE OTHER THAN THE RECIPIENT IS UNAUTHORIZED AND
STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS FAX IN ERROR, PLEASE NOTIFY THE MEDIVIEW UM DEPARTMENT.
UM PHONE #: 512-978-8100
UM FAX #: 512-901-9724
Seton Health Plan
Coverage Guidelines
Varicose Vein Referral
Policy:
1) Seton Health Plan (SHP) will review Medical Assistance Program (MAP) patient
referrals for varicose vein evaluations.
2) Primary care physician will submit varicose vein evaluation requests to SHP and
include supporting documentation (i.e. conservative measures taken, physical
findings and related test results).
3) SHP will approve an evaluation visit at Austin Radiology Associates (ARA) if the
following criteria have been met:
> No significant symptomatic improvement in response to 3-month trial of fitted
elastic support hose AND
> Objective complications — symptoms causing clinically significant functional
impairment as indicated by 1 or more of the following: AND
o Leg pain
o Leg fatigue
o Leg edema
> Ultrasound lower extremities to RIO DVT OR
> 1 or more of the following complications or recurrent symptoms:
o Bleeding from a varicosity that has eroded skin
o Large superficial varices around skin ulcer
o Persistent or recurrent venous stasis ulcer
4) Initial evaluation authorization for ARA will include the following:
> 99241 — Consult x 2
> 93970 — Duplex Doppler
5) If ARA determines that intervention is required they will contact SHP to obtain
authorization. Procedure codes for EVLT will depend on patient’s condition and may
include the following codes: 36478; 37799; 37765; 37766; 36470; 36471; 36479
Pre-Certification Form
Medical Management Dept.
Phone #: (512) 324-3135
Fax #: (512) 324-1936
Polysomnography- Sleep Study Authorization Form
This form should be completed by the person who has a thorough knowledge of the patient’s current clinical presentation and his/her
treatment history. Please complete ALL parts as clearly and as specifically as possible. Omissions, generalities, and illegibility will result
in the form being returned as an incomplete request.
Plan Name
MAP
Seton Care Plus
Charity
CitylCounty Community Clinic (CCHC)
*Request
*Phone #:
*Fax:
*Submitted
Date:
by:
*Patient Name:
*DOB:
*Patient’s ID Number:
Diagnosis and ICD=9 code:
*PCP or Requesting Provider Name:
*Requested Place of Service:
☐ SNW
☐ SMCW
☐ SMCH
☐ DCMCCT
☐ First Available
oREQUEST FOR INITIAL POLYSOMNOGRAM — SPLIT NIGHT (CPAP applied half night if AASM criteria met)
(Both Sections Need To Be Completed)
u Patient awakens with a sense of gasping, choking, or suffocations
u An observer of the patient’s sleep reports repeated pauses in breathing, lasting more than 10 seconds, gasping or choking during sleep
u Awakening of the patient in a state of terror later attributed to the inability to move air through his/her upper airway
u Patient has to fight off sleep while engaging in activities or actually falls asleep unintentionally in the absence of such apparent causes as use of
potentially sedating medications, etc.
Epworth Sleepiness Scale (Required)
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent
times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to
choose the most appropriate number for each situation:
0 = would never doze; 1 = slight chance of dozing; 2= moderate chance of dozing;
3- high chance of dozing
Situation
Chance of dozing (score 0 — 3)
Sitting and reading
Watching TV
Sitting, inactive in public placed (e.g. theater or meeting)
As a passenger in a car for an hour without a break
Lying down at rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL
o
OTHER CLINICAL FINDINGS:
o
REQUEST FOR REPEAT SLEEP STUDY
E
E
E
Copy of previous sleep study submitted with this request
Indication is following a recent positive first night sleep study, where titration was not performed.
Other indication: Please provide details as to why another sleep study is required:
Requesting Provider
Signature and Date:
SHP AUTHORIZATION
NUMBER:
COMMENTS:
Conum/internal guidelines/current guidelines/Polysomnography Request Form 2_22.2011 DRAFT
AUTH
DATES:
Handbook for the
Central Health
MEDICAL ACCESS PROGRAM
SUBROGATION
Subrogation is the right to recover amounts paid by a government-sponsored plan that
are the obligation of other payers (such as an insurance company). If you are injured or
become ill under circumstances in which a third party may legally be obligated to pay
the medical, dental and/or pharmacy expenses, MAP will pay your covered expenses.
MAP reserves the right, however, to be reimbursed for all medical expenses from the
settlement or judgment paid by a third party. Other providers may also have
subrogation rights in any settlement or judgment made by a third party.
EXCLUSIONS
Services and related items excluded from coverage by the Medical Assistance Program
(MAP) include but are not limited to the following list. MAP does not cover items on this
list.
1.
All services that have been denied through pre-authorization by the Medical
Assistance Program;
2.
Services not provided within the MAP designated network, unless pre-authorized;
3.
Services and supplies to any individual who is a resident or inmate in a public
institution;
4.
In-patient hospital and related services for a patient in an institution for
tuberculosis, mental disease, or a nursing section of a public institution for the
intellectually disabled;
5.
Services provided for any work-related illness, injury or complication thereof
arising out of the course of employment for which Worker’s Compensation
Benefits or any other similar regulation of the United States are provided or should
be provided according to the laws of the state, territory or subdivision thereof
governing the employer under which such illness or injury occurred;
6.
Services or supplies provided in connection with cosmetic surgery except as
required for the repair of accidental injury if the initial treatment is received within
12 months of the accident in which the injury was sustained, or for improvement
of the functioning of a malformed body member, or when prior authorization is
obtained for other medically necessary purposes;
7.
Services, supplies and medications for which benefits are available under a
manufacturer’s Patient Benefit Program, or any other contract policy or insurance
which would have been available in the absence of the Medical Assistance
Program;
8.
Services payable by any health, accident, or other insurance coverage; or by any
private or other governmental benefit system, or any legally liable third party;
The Medical Access Program serves the healthcare needs of eligible residents in Travis County
and is funded by Central Health.
Page 1— Revised 04/13/2012
Handbook for the
Central Health
9.
Services, supplies or medications considered experimental or investigational, i.e.,
services and items which have not been approved for marketing by the Food and
Drug Administration Services;
10.
Supplies or medication related to infertility;
11.
Any services to include, but not be limited to, drugs, surgery, medical or
psychiatric care or treatment for transsexualism, gender dysphoria, sexual reassignment or sex change;
12.
Procedures that relate to obesity, obesity therapy and/or special diets (including
medically supervised fasting and liquid nutrition) related to weight reduction
whether necessitated by surgery or a specifically identified medical condition;
13.
Services provided by an interpreter;
14.
Services provided by a relative of the enrollee or a member of his or her
household;
15.
Services and supplies that are provided under any governmental plan or law under
which the individual is or could be covered (e.g., Victims of Crime, Texas
Rehabilitation Commission, Veteran’s Benefits, Medicare, Medicaid, TRICARE,
CHAMPUS, etc.);
16.
Co-insurance fees and deductibles. MAP is not a secondary payer for any other
insurance or governmental health care program, nor does MAP coordinate benefits
with any other payer;
17.
Services not medically necessary, which are not incident to and necessary for the
treatment of an injury or illness;
18.
Acute hospital services and supplies provided as an inpatient to the extent that it is
established upon review of the claim submitted that the enrollee’s condition did
not require a hospital level of care and could have been provided safely at a lesser
level of care;
19.
20.
Services resulting from or in connection with the commission of any illegal act,
occupation or event (including the commission of a crime or violation of conditions
of probation) if the covered individual is incarcerated;
21.
Services resulting from or in connection with any acts of war, declared or
undeclared, or any type of military conflict, charges incurred due to diseases
contracted or injuries sustained in any country while such country is at war or
while en route to or from any such country at war, charges resulting from
illness/injuries incurred while engaged in military services;
22.
Inpatient and Intensive outpatient rehabilitation;
23.
Charges for custodial or sanitaria care, rest cures, or for respite care;
Handbook for the
Central Health
24.
Care and treatment of mental and/or nervous disorders, psychiatric treatment or
individual, family, or group counseling services unless as a co-morbidity or
secondary diagnosis during a medical inpatient stay;
25.
Treatment programs for substance abuse and/or detoxification.
26.
Non-emergency air transport;
27.
Private room except when appropriate documentation of medical necessity is
provided;
28.
Chiropractic services/treatment;
29.
Rolfing;
30.
Acupuncture, acupressure, or biofeedback;
31.
Services rendered by a massage therapist;
32.
Hypnosis;
33.
Eye refractions, eye glasses, eye exercises, contact lenses, or other corrective
devices, including materials and supplies, or for the fitting or examinations for
prescribing, fitting or changing of these items;
34.
Whole blood or packed red cells that are available at no cost to the client;
35.
Autologous blood donations;
36.
Blood clotting factors;
37.
Luxury/entertainment items (e.g., TV, video, beauty aids, etc.);
38.
Charges/fees for completing or filing required forms/pre-authorizations;
39.
Charges which accumulate during any period of time in which the client removes
rental equipment from the delivery site and fails to immediately notify the Medical
Assistance Program of the new location;
40.
Autopsies;
41.
Cellular Therapy;
42.
Chemolase injections (Chemodiactin, Chymopapain);
43.
Chemonucleolysis intervertebral disc;
44.
Dermabrasion;
45.
Dialysis (in-patient or out-patient) or supplies related to dialysis, except for acute
conditions not related to chronic renal failure while in the inpatient setting;
46.
Educational counseling;
47.
Ergonovine provocation test;
48.
Fabric wrapping of abdominal aneurysms;
49.
Hair analysis;
Handbook for the
Central Health
50.
Histamine therapy - intravenous;
51.
Professional component of Hospice Services
52.
Hyperactivity testing;
53.
Hyperthermia;
54.
Immunotherapy for malignant disease;
55.
Immunizations required for travel outside the United States;
56.
Implantations (e.g., silicone, saline, penile, etc.);
57.
Joint sclerotherapy;
58.
Laetrile therapy;
59.
Organ transplants, medications and/or treatments associated with the transplant;
60.
Orthodontic treatment, root canal, crown, and bridge procedures;
61.
Specialized pain management programs and/or treatment designed to provide
chronic pain care unless provided through contracted MAP providers
62.
Prosthetic eye or facial quarter;
63.
Radial and hexagonal keratotomy or refractive surgeries;
keratoprosthesis/refractive keratoplasty;
64.
Routine circumcision for clients one year of age or older;
65.
Sterilization reversal;
66.
Tattooing and/or tattoo removal;
67.
Thermogram;
68.
TORCH screen;
69.
Adaptive equipment for daily living such as eating utensils, reachers, handheld
shower extensions, etc.;
70.
Admission kits;
71.
Air cleaners/purifiers;
72.
Any equipment, supplements, or supplies not ordered by a physician or provider
and/or not considered appropriate and necessary to treat a documented medical
condition/disease process;
73.
Augmentive communication devices, e.g., TTY device, artificial voice box, and
machinery of this nature;
74.
Bed cradles;
75.
Bladder stimulators (pacemakers);
76.
Car seats;
Page 4— Revised 12/2013
Handbook for the
Central Health
77.
Cervical pillows;
78.
Electric wheelchairs or scooters (outpatient);
79.
Enuresis monitors;
80.
Equipment or services not primarily and customarily used to serve a medical
purpose (e.g., an air conditioner might be used to lower room temperature to
reduce fluid loss in a cardiac patient or a whirlpool bath might be used in the
treatment of osteoarthritis, however because the primary and customary use of
these items is a non-medical one, they cannot be considered as medical
equipment);
81.
Evaluations for learning disabilities;
82.
Feeding supplements (e.g., Ensure, Osmolyte) and supplies for long-term use;
83.
Hearing aids;
84.
Home and vehicle modifications, including ramps, tub rails/bars;
85.
Humidifiers, except when used with respiratory equipment (e.g., oxygen
concentrators, CPAP/BIPAP, nebulizers, or for clients with a tracheostomy ;
86.
Over bed tables;
87.
Implantable medication pumps and related supplies, with the exception of insulin
pumps and related supplies;
88.
Prosthetic breasts and mastectomy bras;
89.
Thermometers;
90.
Vocational, educational, exercise, and recreational equipment;
91.
Waist/gait belts;
92.
Whirlpool baths and saunas;
93.
Treatment or correction of temporomandibular joint (TMJ) dysfunction;
94.
Refills or prescriptions in excess of the number specified by the Doctor, or refills
dispensed one year or more after the date of the Doctor’s original order.
REVIEW OF BENEFITS
Review of benefits occurs on a yearly basis. Notice of benefit changes will be sent to
current MAP enrollees thirty (30) days prior to implementation. Further information on
MAP can be found at www.medicalaccessprogram.net. The Provider Handbook for
MAP is posted on the website and contains more detailed information.
Page 5— Revised 12/2013
Provider Handbook
6. Health Services
Provider Handbook
Health Services
Outpatient case management
Inpatient case management
Quality Improvement
Credentialing
Compliments and Complaints
Health Services
Outpatient case management
The purpose of the outpatient case management program is to maintain MAP
patients in a quality oriented and medically appropriate environment,
promoting optimal outcomes through early intervention cost effectiveness,
while utilizing community and other available resources. The outpatient case
management program promotes accessibility, availability, and effectiveness of
care. It also strives to improve quality of life outcomes and monitor cost of
care.
Case Management Activities:
1. Assist in locating and linking to alternative sources of care and
funding.
2. Negotiate fair and accurate reimbursement.
3. Assist primary care physician to provide quality care by offering
coordination of services needed for the patient.
4. Eliminate barriers to care and services by providing innovative
solutions that will meet the patient’s need in a cost effective manner.
5. Involve the patient and the family throughout the case management
process.
6. Serve as an advocate to coordinate and optimally utilize health care
and community related services for the patient.
Inpatient case management
Inpatient case management strives to ensure that all inpatient services and
treatments are medically appropriate and rendered in the appropriate setting.
Inpatient case management provides discharge planning and communicates
further case management needs to outpatient case management. Case
management also ensures surveillance activities for quality and barriers to
care/avoidable day tracking. Inpatient case management may serve as a
resource to the physician to assist in finding and coordinating alternative
services for the enrollee. Inpatient case management will provide all the
components of outpatient case management in the inpatient setting and
provide a smooth transition of patient services from the inpatient to the
outpatient setting.
Medical Management
Page 1 of 2
Revised 12/2013
Quality Improvement
The Quality Improvement (QI) Program of Central Health seeks to ensure
that the services provided through the District for enrollees meet all
clinical and administrative standards.
To meet that goal the Quality Improvement (QI) program is designed to
provide a formal ongoing process by which the District’s participating
providers and practitioners will be measured for quality of services, both
clinical and administrative, provided to enrollees.
Credentialing
The Provider will participate in the formal process through which Central
Health or its designee collects, verifies, and evaluates the professional
credentials and qualifications of licensed individual providers against the
criteria, standards, and requirements established by the District for
providing health care services to Eligible Patients.
Central Health endeavors to provide the best medical care to the persons
it serves. The District invites enrollees to let us know when they receive
exceptional services and when they feel the services were not successful
in meeting their specific needs.
Please encourage enrollees to discuss any concerns or questions about
their treatment or medical care with her or his primary care provider. If
the enrollee is unable to resolve issues with the primary care office, please
give the enrollee our telephone number (512) 978-8150.
Medical Management
Page 2 of 2
Revised 12/2013
Provider Handbook
7. CONTRACT PROVIDERS
Provider Handbook
CONTRACT PROVIDERS
Primary Care
Dental Services
Diabetic Retinal Screening
Durable Medical Equipment
Custom-made Orthotics and Orthotic Care
Radiation Oncology
Urgent Care
Contract Providers
Page 1 of 1
09/15/2011
CONTRACT PROVIDERS
PRIMARY CARE: CommUnityCare
A.K. Black
ARCH
Blackstock Family Health Center
David Powell
Del Valle
East Austin
Manor
North Central Health Center
928 Blackson Avenue
Austin, TX 78752
Telephone: 512-978-9740
Fax: 512-978-9741
500 East Seventh Street
Austin, TX 78701
Telephone: 512-978-9920
Fax: 5112-978-8129
1313 Red River
Suite 100
Austin, TX 78702
Telephone: 512-324-8600
Fax: 512-324-8612
4614
North IH-35
Austin, TX 78751
Telephone: 512-978-9100
Fax: 512-978-9140
3518 FM 973
Austin, TX 78617
Telephone: 512-978-9760
Fax: 512-978-9767
211 Comal Street
Austin, TX 78702
Telephone: 512-978-9200
Fax: 512-978-9220
600 West Carrie Manor
Manor, Texas 78653
Telephone: 512-978-9780
Fax: 512-978-9781
1210 West Braker Ln.
Austin, TX 78758
Telephone: 512 978-9300
Primary Care: CommUnityCare
Page 1 of 2
Revised 1012
Continued: CommUnityCare
Oak Hill
Pflugerville
Hancock
Rosewood Zaragosa
Rundberg
South Austin
UT Family Wellness Center
William Cannon
8656 Highway 71 West
Suite C
Austin, TX 78735
Telephone: 512-978-9820
Fax: 512-978-9830
15822 Foothill Farms Loop
Pflugerville, TX 78660
Telephone: 512-978-9840
Fax: 512-978-9860
1000 E. 41st St.
Suite 960
Austin, TX 78751
Telephone: 512-978-9940
Fax: 512-901-9702
2802 Webberville Road
Austin, TX 78702
Telephone: 512-978-9400
Fax: 512-978-9457
825 East Rundberg Lane, B-1
Austin, TX 78753
Telephone: 512-978-9600
Fax: 512-978-9601
2529 South First Street
Austin, TX 78704
Telephone: 512-978-9500
Fax: 512-978-9558
2901 North IH 35
Austin, TX 78722
Telephone: 512-232-3900
Fax: 512-471-1455
6801 South IH-35
Suite 1-E
Austin, TX 78745
Telephone: 512-978-9960
Fax: 512-912-7810
Primary Care: CommUnityCare
Page 2 of 2
Revised 11/13/2012
Medical Assistance Program
CONTRACT PROVIDERS
PRIMARY CARE: Lone Star Circle of Care
GCC Adult Clinic
2423 Williams Dr, Suite 113
Georgetown, TX 78628
Phone: 512- 930-0820
Fax: 512-864-7238
GCC Pediatric
612 E. University Avenue
Phone: 512-930-5437
Fax: 512-930-7400
Granger Medical
115 W. Davilla
Granger, TX 76530
Phone: 512-859-2251
Fax: 512-859-2575
RR OB/Gyn
2300 Round Rock Ave, Suite 208
Round Rock, TX 78681
Phone: 512-828-3300
Fax: 512-255-5307
RRHC
2120 North Mays, Suite 430
Phone: 512-255-5120
Fax: 512-255-5268
AW Grimes
2051 Gattis School Rd, Suite 250
Phone; 512-238-5400
Fax: 512-238-5492
Ben White Health Center
1221 W. Ben White Blvd, Suite B-200
Austin, TX 78704
Phone: 512-524-9249
Fax: 512-448-1311
TAMU — OB/Gyn
3950 N. AW Grimes, Suite n103
Phone: 512-524-9275
Fax: 512-238-9279
TAMU Pediatrics
Phone: 512-524-9281
Fax: 512-218-0515
TAMU Adolescent
Phone: 512-524-9253
Fax: 512-218-1249
TAMU Family Health
3950 N. AW Grimes, Suite n301a
Phone: 512-524-9257
Fax: 512-218-1377
TAMU — OB/Gyn
Phone: 512-524-9275
Fax: 512-238-9279
Primary Care: Lone Star Circle of Care
Page 1 of 1
Revised 09/15/2011
CONTRACT PROVIDERS
PRIMARY CARE
Paul Bass Clinic
People’s Community Clinic
1400 North IH-35
Suite CL 400
Austin, TX 78701
Telephone: 512-324-8070
Fax: 512-324-8074
2909 North IH-35
Austin, TX 78722
Telephone: 512-478-4939
Fax: 512-708-1835
Primary Care
Page 1 of 1
Revised 03-01-2009
CONTRACT PROVIDERS
DENTAL SERVICES: CommUnityCare
RBJ Dental Clinic
North Central Dental Clinic
South Austin Dental Clinic
Southeast Health and Wellness Center
Ben White Dental
15 Waller Street
Austin, TX 78702
Telephone: 512-978-9895
Fax: 512-978-9900
1210 W. Braker Ln, 2nd floor
Austin, TX 78758
Telephone: 512-978-9300
Fax: 512-279-2555
2529 South First St.
Austin, TX 78704
Telephone: 512-978-9865
Fax: 512-978-9869
2901 Montopolis Drive
Austin, TX 78741
Telephone: 512-978-9901
1221 W. Ben White, Suite 112B
Austin, TX 78704
Phone: 512-978-9700
Fax: 512-279-2307
Dental Services
Page 1 of 1
Revised 06/20/2012
CONTRACT PROVIDERS
DIABETIC RETINAL SCREENING
801 West 38th Street, Suite 200
Austin, TX 78705
Austin Retina Associates
Brian B. Berger, MD
Richard B. Briggs, MD
170 Deepwood Drive, Suite 105
Telephone: 512-451-0103
Fax: 512-451-9276
3705 Medical Parkway, Suite 410
Austin, TX 78705
Telephone: 512-454-4851
Fax: 512-454-5853
6801 Manchaca Road
Austin, TX 78745
Telephone: 512-444-2015
Fax: 512-444-2010
Diabetic Retinal Screening
Page 1 of 1
Revised 02-07-2011
CONTRACT PROVIDERS
DURABLE MEDICAL EQUIPMENT
Austin Wheelchair
Applied Orthotics
5555 North Lamar Blvd. Suite 107
Austin, TX 78751
Telephone: 512-452-7988
Fax: 512-452-7738
7801 North Lamar Blvd.
Austin, TX 78752
Telephone: 512-380-0259
Fax: 512-380-0281
Durable Medical Equipment
Page 1 of 1
Revised 03-01-2009
CONTRACT PROVIDERS
CUSTOM-MADE ORTHOTICS AND ORTHOTIC CARE
Applied Orthotics
Hanger Clinic
The Orthotic Specialist
7801 North Lamar Blvd., Suite F-30
Austin, TX 78752
Telephone: 512-380-0259
Fax: 512-380-0281
8000 Anderson Square Rd., Suite 301-A
Austin, TX 78757
Telephone: 512-377-2323
Fax: 512-374-9993
2102 Blalock Drive, Suite 102
Austin, TX 78758
Telephone: 512-490-1255
Fax: 512-490-1297
Custom-made Orthotics and Orthotic Care
Page 1 of 1
Revised 09/12/2011
CONTRACT PROVIDERS
RADIATION ONCOLOGY
Austin Cancer Center
Austin Cancer Center Northwest
North Austin Cancer Center
2600 East MLK Jr. Blvd.
Austin, TX 78702
Telephone: 512-505-5500
Fax: 512-505-5590
1111 Research Blvd.
Austin, TX 78759
Telephone: 512-531-5200
Fax: 512-531-5280
12221 North MoPac Expressway
Austin, TX 78758
Telephone: 512-901-1180
Fax: 512-901-1190
Radiation Oncology
Page 1 of 1
Revised 03-01-2009
CONTRACT PROVIDERS
URGENT CARE
NextCare Urgent Care
Austin — William Cannon
Austin — Cedar Park
Round Rock
Georgetown
6001 West William Cannon #302
Austin, TX 78749
Telephone: 888-381-4858
351 Cypress Creek Rd #103
Cedar Park, TX 78613
Telephone: 888-381-4858
1240 East Palm Valley Road
Telephone: 888-381-4858
900 North Austin Avenue #105
Telephone: 888-381-4858
Urgent Care
Page 1 of 1
Revision 06/20/2012
8. SPECIALTY CARE
University Medical Center
at Brackenridge
Specialty Clinics
University Medical Center Brackenridge
Specialty Clinics
Table of Contents
Clinic Rotation Schedule
5
Asthma Clinic
7
Breast Surgery Clinic
8
Cardiology Clinic
10
Cardiology Clinic Worksheet
12
Dermatology Clinic
13
Endocrinology Clinic
14
E n d o c r i n o l o g y Clinic Worksheet
ENT Clinic
ENT Overbook Fax Request
16
18
20
Eye (Ophthalmology) Clinic
22
Foot Clinic
24
Fracture Clinic
25
Gastroenterology Clinic
26
G a s t r o e n t e r o l o g y Clinic Worksheet
27
Gynecology/Oncology Clinic __________________________________________________33
Hematology Clinic___________________________________________________________35
H e m a t o l o g y Clinic Worksheet
36
Neurology Clinic
38
N e u r o l o g y Clinic Worksheet
40
EMG Referral Form
42
Oncology Clinic
44
Orthopedic Clinic
46
Pulmonary Clinic
47
Specialty Clinics
Table of Contents (continued)
Renal/Hypertension Clinic
48
Renal/Hypertension Clinic Worksheet
49
Rheumatology Clinic
50
R h e u m a t o l o g y Clinic Worksheet
51
Surgery Clinic
53
Urology Clinic
55
Urology C l i n i c Worksheet
57
Referral Form — UMCB Specialty Clinics
58
Seton Imaging and Radiology — Required Labs
59
Diagnostic Order Forms
60
A u d i o l o g y T e s t i n g ________________________________ _______________ 62
Cardiology Electroneurodiagnostic Testing ________________________________ _ 64
Physical Therapy ___________________________________ _66
Map of Seton Rehabilitation Facilities
67
Directions to Paul Bass Clinic (English)
68
Directions to Paul Bass Clinic (Spanish)
69
Map of Paul Bass Clinic
70
First-Time Referring Physician Setup Form
Physician Exclusions List Search
Physician License Practice Status
Pg.4
Specialty Clinics
Friday
Thursday
Wednesday
Tuesday
Monday
Day
Specialty Clinic
Anticoag
Breast
Cardiology
Cast/Fractures
Medicine
Psychiatry
Urology
Surgical Oncology
Anticoag
Dermatology
Eye
Gyn/Onc
Hem/Onc
Medicine
Orthopedics
Rheumatology
Surgery
Anticoag
Asthma/Allergy
Eye (Ophthalmology)
GI
Hem/Onc
Medicine
Renal
Surgery
Anticoag
Endocrinology
ENT
Hem/Onc
Medicine
Neurology
Palliative Care
Surgery
Anticoag
Derm Suture Removal
Eye-Visual Fields
Hem/Onc
Medicine
Neurology
Neuro Epilepsy
Neuro Trauma
Podiatry
Pulmonary
Rheumatology
UTHSCSA
Frequency
1st, 3rd
each week
2nd, 3rd, 4th
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
2nd, 4th
each week
each week
each week
each week
each week
each week
each week
each week
1st, 2nd, 3rd
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
each week
2nd
2nd, 4th
1st, 3rd
1st, 3rd
each week
2nd, 4th
Location
Sub-Specialty 220
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Paul Bass Clinic
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Sub-Specialty 220
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Paul Bass Clinic
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Paul Bass Clinic
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Sub-Specialty 220
Shivers 217
Paul Bass Clinic
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Sub-Specialty 220
Paul Bass Clinic
Paul Bass Clinic
Shivers 217
Pg.5
Specialty Clinics
PAUL BASS CLINIC
AM
MONDAY
Cardio 2, 3, 4 wk
TUESDAY
Derm wkly
Psychiatry wkly
Rheum wkly
WEDNESDAY
GI wkly
THURSDAY
Endo wkly
FRIDAY
Pulm 1, 3 wk
ENT 1, 2, 3 wk
Rheum wkly
Derm. Suture Removal
wkly
Medicine wkly
Medicine wkly
Medicine wkly
Medicine wkly
Medicine wkly
PM
SHIVERS CENTER
AM
PM
MONDAY
Surg/Onc wkly
TUESDAY
Hem/Onc wkly
WEDNESDAY
Hem/Onc wkly
THURSDAY
Hem/Onc wkly
FRIDAY
Hem/Onc wkly
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
Palliative Med Wkly
Chemo/Infusion
Chemo/Infusion
Breast Surgery wkly
Gyn/Onc wkly
Hem/Onc wkly
Hem/Onc wkly
UTHSCSA 2,4 wk
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
Chemo/Infusion
SUITE 220 Sub-Specialties
MONDAY
Cast wkly
TUESDAY
Anti-coag. Wkly
WEDNESDAY
Anti-coag. Wkly
THURSDAY
Anti-coag. Wkly
FRIDAY
Anti-coag. Wkly
Orthopedics wkly
Eye wkly
Neurology wkly
Eye Visual Field wkly
Renal 1,2,3,4 wk
EMG
Neuro Trauma 2,4 wk
AM
Neuro Epi 2 wk
PM
Anti-coag. 1, 3 wk
Surgery wkly
Asthma 2,4 wk
Urology wkly
Eye wkly
Allergy/Pulm 2, 4 wk
Surgery wkly
Pg.6
Surgery wkly
Neurology wkly
Podiatry 1, 3 wk
University Medical Center at Brackenridge
Specialty Clinics
Asthma Clinic
Appropriate patients for referral:







Patients with refractory asthma having difficulty controlling symptoms despite
appropriate treatment
Patients needing evaluation of their current asthma management plan
Patients with recent ED visit or hospitalization for asthma
Patients with chronic urticaria
Patients with immunodeficiency
Patients with chronic sinusitis
Patients needing skin testing for allergen avoidance counseling
Documentation required for scheduling an appointment:
1.
2.
3.
4.
Completed Referral form
Past Medical History (PMH)
Current medication list
Most recent progress note describing condition for which patient is being
referred.
5. If reports are available, include with referral. If patient has not had testing, reports
are not required for scheduling appointment.
Examples of report: chest films, pulmonary function testing, labs, skin testing
results.
Revised May 2015
Pg.7
Specialty Clinics
Breast Surgery Clinic
Scope


To evaluate and treat newly diagnosed breast cancer patients.
To provide consultation and care that is beyond the routine abilities of the
primary care physicians.
Appropriate patients for referral include:










Positive pathology per biopsy
Obvious tumor growth by exam (nipple inversion, dimpling, peau d ‘orange,
ulceration)
Bloody nipple discharge
Fibro adenomas over 2 cm
BRCA positive patients
Abscess unresolved by full course of antibiotics
BIRADS 3, 4, and 5 Mammogram and US (please see additional information
under breast mass below)
Breast Papilloma’s
Paget’s disease
Atypical Hyperplasia
Please do NOT refer the following patients:











Fibro adenomas under 2 cm
Breast Cyst
Breast pain
Benign masses diagnosed by pathology
Extra breast tissue
Extra nipple
Nipple discharge with abnormal prolactin levels
High risk patients for BRCA testing (please refer to the Myriad website for
assistance)
Mastitis
Breast mass on exam but normal imaging (BRADS 1-2). Recommendation:
Repeat imaging as suggested by radiology along with clinical breast exam.
Consider ultrasound guided biopsy if clinically indicated.
Axillary mass with normal breast imaging
Documentation required for scheduling all appointments:




Completed referral form
Mammogram or ultrasound withing the past 3 months
History and Physical
Current medications
Pg.8
Specialty Clinics
Breast Mass

If Mammogram or ultrasound suggests biopsy, please obtain biopsy and refer
with FINAL pathology report. For microcalcifications, order stereotactic biopsy.
For breast mass, order ultrasound guided biopsy. To schedule either of these at
a Seton facility call Central Scheduling at 512-324-1199.
Nipple Discharge


Serum Prolactin level
cytology of nipple discharge


BRCA results
Any surgical reports related to BRCA results (mastectomy/oopherectomy)
Revised May 2015
Pg.9
Specialty Clinics
Cardiology Clinic
Scope:


Cardiology consultation
On-going cardiology care for some chronic cardiac conditions which require
adjustment in Therapy. Once stable, ongoing follow up by PCP.









CAD (Coronary Artery Disease) previously evaluated with stress test or
angiogram
Uncontrolled Angina despite appropriate medical treatment
Refractory Heart failure CHF (Congestive Heart Failure) previously evaluated
with echocardiogram and with symptoms despite standard treatment
Documented arrhythmias (excluding PACs and PVCs)
Syncope (suspicious of cardiac source) – refer after EKG, Echo and Holter have
been performed
Documented significant valvular disease
Newly diagnosed CHF
New onset or unstable AFIB
Patients discharged from the hospital requiring Cardiology follow up will be seen
no later than 1 week.
Please do NOT refer patients with the following:






Atypical chest pain without stress test results
Dizziness (refer to ENT)
Palpitations without documented arrhythmia
Pre-operative clearance without a cardiac problem
Pediatric patients age < 18
Pacemaker/ICD Management (refer to Cardiac Electrophysiology)
1.
2.
3.
4.
referred.
5. EKG within the last 3 months
Pg.10
Specialty Clinics
6. Other studies if appropriate including those on the following worksheet (e.g.,
stress test, echo, Holter Monitor, etc.)
Revised May 2015
Pg.11
Specialty Clinics
Cardiology Clinic Worksheet
Chest Pain


Normal EKG:
o Patient able to exerciseExercise stress test results
o Patient unable to exercisePharmacologic SPECT results
Abnormal EKG:
o Patient able to exerciseExercise SPECT results
o Patient unable to exercisePharmacologic SPECT results
Refractory CHF



EKG results
Echocardiogram results
Chest X-Ray results/film
Pulmonary HTN


EKG results
Arrhythmia


12 lead EKG
24 hour holter monitor digital recording
Heart Murmur

Revised May 2015
Pg.12
Specialty Clinics
Dermatology Clinic
Scope:

To provide general dermatology consultation and diagnostic testing with referral
back to the Primary Care Physician for management.







General skin problems - < 4 cm or located on face or scalp
Symptomatic skin lesions or moles
Lesions or moles suspicious for cancer
Dermatoses such as psoriasis, eczema, contact dermatitis, etc
Alopecia (hair loss)
Onchymycosis
Keloids





Cosmetic Problems
Acne
Rosacea
Pediatric patients age <18
Eyelid lesions – refer to Eye Clinic






referred.
Documentation of prior treatment
Final path report if biopsy was done
Revised May 2015
Pg.13
Specialty Clinics
Endocrinology Clinic
Scope

To provide consultations at a subspecialty level in endocrinology.














Lipid Abnormalities in a patient with family or personal history of early CVD, inability
to achieve LDL-C<100 and/or non-HDL-C<130 in a patient with CVD or a CVD
equivalent who cannot tolerate a statin or who is taking a maximum dose of statin
and Hypertriglyceridemia, defined as fasting Tg level>500 or non-fasting >800
Thyroid Nodule
Thyroid Cancer
Hyperthryoidism
Difficult to Control Hypothyroidism
Osteoporosis and osteopenia
Calcium and Parathyroid Disorders
Pituitary Masses and Disorders
Adrenal Masses and Disorders
Amenorrhea & Galactorrhea
Hypogonadism; referral for new diagnoses must include two low testosterone levels
collected on separate days before 9AM
Type 1 Diabetics
Type 2 Diabetics requiring ≥ 300 units of insulin daily or U-500 insulin
Diabetes being managed with an insulin pump



Pediatric patients < 18 years old
Diabetic patients unless already using an Insulin Pump or requiring ≥ 300 units of
insulin daily or U-500 insulin
Gender Dysphoria / Transsexual Patients




referred.
Pg.14
Specialty Clinics


Recent pertinent labs (Appropriate labs per worksheet, drawn within the past
month, substantiating the disorder. Please send lab flow sheets if they exist.)
Recent pertinent scans or X-rays
Revised May 2015
Pg.15
Specialty Clinics
Endocrinology Clinic Worksheet

Difficult to Control Lipid Abnormalities
o Fasting Lipid Panel
o Fasting Glucose

Thyroid Nodule
o Thyroid Ultrasound within past 12 months for nodules ≥ 1cm
o TSH
o Free T4

Hyperthyroidism
o TSH
o Free T 4
o I-123 Iodine uptake and scan

Difficult to Control Hypothyroidism
o TSH
o Free T4

Osteoporosis
o DXA Scan Results
o CMP
o TSH
o Intact PTH
o 25 (OH) Vitamin D
o SPEP
o UPEP
o 24 hour urine for calcium and creatinine

Calcium and Parathyroid Disorders
o Intact PTH
o Serum Calcium
o Serum Albumin
o 24 hour urine for calcium and creatinine
Revised May 2015
Pg.16
Specialty Clinics
Endocrinology Clinic Worksheet (continued)

Pituitary Masses and Disorders
o MRI of the Sella Turcica
o Serum Prolactin Level
o TSH
o Free T 4
o LH
o FSH
o IGF-1
o 8am Serum Cortisol Level

Adrenal Masses and Disorders
o BMP
o 8am Plasma Renin Activity
o Aldosterone
o 24 hour urine for Free Cortisol, Creatinine, Metanephrines and Catecholamines

Amenorrhea & Galactorrhea
o Prolactin level
o TSH
o FSH
o LH

Diabetes
o Hgb A1C
o CMP
o Fasting Lipid Panel
o Urine spot microalbumin and creatinine

Hypogonadism
o 8am Total Testosterone
o Prolactin level
o TSH
o FSH
o LH
o For patients age < 40: Ferritin, Serum Iron, TIBC
Revised May 2015
Pg.17
Specialty Clinics
ENT Clinic
(Head and Neck Surgery)

Provide care that is beyond the routine abilities of primary care physicians. Patients
referred to the clinic should have problems that may require surgery or advanced
ENT physician care.





















Masses in the head and neck
Suspected Cancer
Thyroid Masses
Parathyroid Masses
Bleeding from unknown ENT source
Chronic draining ear discharge persistent despite 3 weeks of treatment with
appropriate topical and oral antibiotics
Hoarseness persistent greater than 6 weeks
Chronic Recurrent Tonsillitis with 4 or more episodes in the past year and/or 2-3
episodes annually over multiple years
Chronic Recurrent Sinusitis evident on CT scan after 3 weeks of appropriate
antibiotic treatment
Obstructive Sleep Apnea (must have completed Sleep Study prior to referral)(less
than 1 yr.)
Vertigo persistent for greater than 6 weeks – need Audio
Tinnitus (must have audiogram prior to referral)
Tympanic Membrane Perforation (must have audiogram prior to referral)
Conductive Hearing Loss (see Note below)
Unilateral Sensorineural Hearing Loss (see Note below)
Bilateral Sensorineural Hearing Loss in individuals less than age 65 (see Note
below)
Ankyloglossia (Tongue tie)
Impacted ear was
Snoring
Tonsilar hypertrophy
Deviated septum
NOTE: Hearing loss must be documented by a formal audiogram at UMCB prior to ENT
referral. Based on UMCB audiogram results, patients may be scheduled in ENT
clinic or referred back to the primary care physician.
Ears with drainage do not need Audiology.
Pg.18
Specialty Clinics



Colds, minor infections, routine sinus problems
TMJ Disorder
Patient with obstructive sleep apnea already on machine and doing well.








referred.
Brief synopsis of prior pertinent treatments
Pertinent imaging studies (send with patient if available)
Pertinent negatives studies (eg. nl EKG, nl CT of brain)
If another specialty has seen patient, send copy of their notes.
Revised May 2015
Pg.19
Specialty Clinics
ENT Overbook Fax Request
This form must be filled out entirely and faxed to (512) 380-7508. This form applies only to
overbook requests from the Clinic for MAP patients.
Patient Name:________________________________________________________________
Authorization Number (if
required)____________________________________________________________________
Reason for
Referral:____________________________________________________________________
Please see patient:
___Next Clinic
___4-8 weeks
___9-12 weeks
Please provide a brief medical justification for overbooking the patient:
Pg.20
Specialty Clinics
Referring
Clinic:_________________________________________________________________
Clinic Phone#:_______________________________________________________________
Clinic Fax#__________________________________________________________________
Referring
Physician:_____________________________________________________________
Patient Contact
Information:____________________________________________________________
Please fax the completed form along with copies of pertinent physician findings, laboratory
studies, and radiological studies. You should receive this form back within 1 week with an
appointment time and date. It is the primary care clinic’s responsibility to notify the patient
with their appointment date and time. If you do not receive the form within 1 week you may
need to re-fax.
For Office Use Only:
___Approved
___Denied
Recommenations______________________________________________________________
________________
____________________________________________________________________________
________________
____________________________________________________________________________
________
____________________________________________________________________________
________
Revised May 2015
Pg.21
Specialty Clinics
Eye (Ophthalmology) Clinic
Scope

To provide medical and surgical evaluation and management of patients with visual
or ocular disorders.
















Blurred vision, unexplained (not related to glasses)
Persistent red eyes greater than 1 week
ALL red eyes with pain or decreased vision
Eye pain
Glaucoma or at risk patients (Positive family history, race, high myopes)
Cataracts – no overbooks allowed per physician
Exophthalmos
Advancing Pterygia
Strabismus or diplopia (double vision)
Lid lesions (cancer or Herpes Zoster)
Abnormal lid contour (ectropion, entropion)
Screening for patients taking Plaquenil
Increased intracranial pressure (Pseudotumor)
Structural brain abnormalities suspected of impairing visual pathway (e.g. pituitary
tumors, A-V malformations, etc.)
Macular degeneration
Diabetic patients for retinal screening





Sudden change in vision (refer to ED)
Flashing lights and floaters (refer to ED)
Patients needing glasses or contact lenses (no refraction is done in the eye clinic)
Hypertensive patients without ocular symptoms
Note: Children failing their vision test at school need to be referred to the Lion's
Club (through the school nurse) where free glasses will be provided.




referred.
Pg.22
Specialty Clinics

Blurry vision, cataracts, glaucoma need optometrist note
Revised May 2015
Pg.23
Specialty Clinics
Foot Clinic
Scope

Examination and treatment (medical and surgical) of ankle and foot pathology.







Foot / ankle deformities*
Bunions *
Ingrown toe nails
Plantar fasciitis (does not need xray)
Ganglion cyst
Foot / ankle pain (need xray)
Ulcerations of the foot in diabetes / neuropathies (no work up needed)




Referrals for routine foot care including diabetic foot checks
Referrals for toenail debridement and/or onychomycosis**
Referrals for orthotics (we cannot get these for patients)




referred.

*Pre-examination x-rays – usually a standing AP and lateral of the affected foot
(feet) is required. X-rays need to be sent to the clinic with the patient
**refer to Derm
Xrays must be less than 1 year old
Revised May 2015
Pg.24
Specialty Clinics
Fracture Clinic
Scope:

To evaluate and stabilize acute closed fractures involving upper & lower
extremities, and manage splinting, casting and x-rays. All other non-traumatic
orthopedic issues should be referred to Ortho Clinic. No emergency care is
rendered in Fracture Clinic.




Patients age 15 and above with acute closed fractures or dislocations verified by
x-ray
Patients with old fractures if experiencing new or worsening pain or deformity, or
patients with new complaints about prior fracture surgery
Sprains and strains seen in the ED
Avulsion fractures, suspected avulsion fractures and stress fractures
Please do NOT refer the following:





Suspected fractures not verified by x-ray
Fractures in pediatric patients age 14 and younger (should be referred to DCMC
Clinics)
Open fractures (send to ED)
Chronic orthopedic issues – Arthritis, Rotator Cuff Tear, Carpal Tunnel Syndrome
(should be referred to Ortho Clinic)
Fractures and injuries involving the hand and wrist including navicular/scaphoid
injuries (should be referred to Plastic Surgery/Hand Clinic)




Radiographs (actual x-ray films, not just transcribed report)
Pertinent ER reports / clinical reports
Pertinent consult reports
Pertinent operative reports
NOTE: Referral RN to review, then print to Xray Room printer: BH/POB/2/Xray
Revised May 2015
Pg.25
Specialty Clinics
Gastroenterology Clinic
Scope

To evaluate complaints and/or abnormal objective findings attributed to the GI
system including liver & pancreas and to recommend diagnostic testing, therapy
and continuing care for these patients.

Please see worksheet
The following are NOT appropriate for referral:


Pediatric patients < 18 years old
Incomplete work up (see worksheet below for recommendations)



Completed referral form including documentation as indicated by worksheet
Most recent lab and imaging results
Specific question being asked
Revised May 2015
Pg.26
Specialty Clinics
Gastroenterology Clinic Worksheet
1. GI Bleeding (occult or symptomatic)
a. CBC
b. Iron, Ferritin
b. Medication history
2. Iron Deficiency Anemia and no evident source
(if no iron deficiency consider hematological evaluation prior to GI referral)
a. CBC
b. Iron, TIBC or Ferritin
c. Stool hemoccult.
3. Abnormal Liver Tests [LFTs First assess alcohol use and review medication
causes
a. Abnormal LFTs on 2 sets of results at least 6 weeks apart
b. Abdominal liver ultrasound
c. Ferritin, Iron, TIBC
d. Acute Viral hepatitis panel
4. Cirrhosis
a. CBC, PT/INR, CMP
b. Acute Viral Hepatitis Panel, hepatitis A antibody total, Hepatitis B surface antibody
total, and Hepatitis B core antibody total.
c. Abdominal/liver ultrasound
d. Documentation of ETOH history
Pg.27
Specialty Clinics
e. Document Hepatitis A and B vaccination according to serologies. (Do not exclude
patient if this is not included but other materials are present.)
f. Recommend Flu/Pneumovax.
5. Hepatitis C Antibody Positive [HCV Ab +]
Check the following and refer to GI if HCV is present by PCR.
a. HCV RNA PCR quantitative & genotype
b. CMP, CBC, HIV antibody
c. Hepatitis A total antibody
d. Hepatitis B surface antigen, surface antibody, core total antibody
e. Abdominal/ liver Ultrasound
6. Hepatitis B Surface Antigen Positive [HBSAg +]
Check the following and refer if HBV is present by PCR.
a. HBV DNA PCR quantitative
b. Hepatitis B surface antigen, surface antibody, e antigen and e antibody
c. CMP, CBC, HIV antibody
d. Hepatitis A total antibody
e. Hepatitis C antibody
f. Abdominal/liver Ultrasound
7. Inflammatory Bowel Disease
a. Previous History
b. Most recent endoscopy and colonoscopy reports
Pg.28
Specialty Clinics
c. Pathology reports.
d. LFTs, CBC, CMP
e. Recommend Pneumovax vaccination
f. Document Hepatitis A and B vaccination according to serologies. (Do not exclude
patient if this is not included but other materials are present.)
g. Recommend flu shot (Must check the type of IBD therapy that the patient is getting
before flu shot).
8. Family History of Colon Polyps or Cancer [any age]
Refer to GI Clinic if 1st degree family history- Age and what relative, 10 years of
diagnosis of relative
9. Chronic Diarrhea (> 3 weeks duration) (refer to GI Clinic for any 1 or more of the
following):
I. Diagnostic uncertainty despite history, physical examination, and laboratory testing
including:
a. CBC, CMP and sedimentation rate
b. Stool C&S, O&P X3
c. C. difficile toxin
d. Stool WBCs
e. HIV
f. Thyroid studies
g. Fecal occult blood X 3
If appropriate clinical history: Celiac panel, Qualitative Fecal fat. Giardia antigen,
cyclospora, microspora, cryptosporidium.
II. History or findings suggestive of malabsorption, or colonic or terminal ileal disease
Pg.29
Specialty Clinics
III. Previous surgery involving extensive resection of ileum, right colon, bypass
procedures, or cholecystectomy
10. Abdominal Pain (refer to GI Clinic for any 1 or more of the following):
I. Diagnostic or therapeutic uncertainty after evaluation, including ALL of the following:
a. Laboratory testing (CBC, CMP, serum amylase, serum lipase, urinalysis, urine
pregnancy test)
b. Noninvasive imaging studies (plain x-rays, ultrasonography, and/or computed
tomography)
II. Abdominal pain in special populations, including 1 or more of the following:
a. Patients > 50 years old
b. HIV-positive patients
c. Immunosuppressed patients
11. Dysphagia
Get ESOPHAGRAM on all patients
12. Dyspepsia (refer to GI Clinic for any 1 or more of the following):
a. Persistent symptoms despite negative H. pylori stool antigen or Urea Breath test
testing and 4 week PPI trial
b. Persistent symptoms despite positive Helicobacter pylori stool antigen or Urea Breath
test testing and eradication therapy.
The Urea Breath test is a good option instead of the stool antigen with the following
precautions:
Patient must fast at least one hour prior to testing
Pg.30
Specialty Clinics
The patient should not take:
Antimicrobials within 4 weeks prior to testing.
Proton pump inhibitors or bismuth preparations within 2 weeks prior to testing.
H2 antaganist within 3 days prior to testing.
Phenylketonuria patients should not have Urea breath test.
Wait a minimum of 4 weeks following treatment prior to Urea Breath testing-because of
false negative results.
c. Patients with 1 or more of the following:
Involuntary weight loss
Gastrointestinal bleeding
Dysphagia
Odynophagia
Unexplained iron-deficiency anemia
Persistent vomiting
Palpable mass or lymphadenopathy
Jaundice
Family history of upper gastrointestinal cancer
Patients 50 years of age or older
13. Gastroesophageal Reflux Disease (GERD) (refer to GI Clinic for any 1 or more of
the following):
a. Symptoms of heartburn or regurgitation that have not responded to 8 week PPI
trial
b. Symptoms of laryngeal origin (eg, dyspnea, cough, hoarseness) that have not
responded to 8 week PPI trial
c. Suspected complicated GERD, as indicated by 1 or more of the following:
Pg.31
Specialty Clinics
Dysphagia
Odynophagia
Bleeding
Weight loss
Early satiety
Choking
Anorexia
Frequent vomiting
d. Symptoms of GERD that have lasted longer than 5 years
14. Chronic Constipation
a. Documentation of fiber, laxatives, stool softeners tried
b. Acute bowel habit change
c. List of medications
d. TSH
e. Serum Calcium
f. CBC
15. Suspected Gastroparesis
FOUR HOUR Gastric Emptying Study
Revised May 2015
Pg.32
Specialty Clinics
Gynecology/Oncology Clinic
Scope


To evaluate newly diagnosed and recurrent or previously treated gynecologic
type cancers.
To evaluate pelvic masses with suspicion for gynecological malignancies.






Any invasive gynecological cancer, newly diagnosed or recurrent
Pelvic masses suspicious for invasive gynecological cancer
Patients receiving treatment for their gynecological cancer
Patients needing surveillance for their gynecological cancer
VIN II and III
Do NOT refer the following patients (Unless there has been a doctor to doctor consult
and is approved by the Gyn/Onc clinic physician)



Any pre-invasive cancers
o CIN I, II, III
o VIN I
o HGSIL or LGSIL on pap smear
o Carcinoma in situ
Fibroids
Simple ovarian cyst
Documentation required for scheduling an appointment

o Completed referral form
o History and physical with documented gynecology exam
o Current medication list and co-morbidities
o Patient demographics
o If already diagnosed, pathology confirming cancer diagnosis
o If previously treated for diagnosis, send all oncology notes and all
treatment records (chemotherapy records, surgical records, radiation
records)
Pg.33
Specialty Clinics

Additional information needed for Ovarian Cancer:
o Any pertinent abdominal or pelvic imaging
o CA125
o Supporting documentation for recurrence if suspected
o If metastatic disease present, send supporting documentation for
metastatic locations.

Additional information needed for Endometrial, Cervical, and Uterine
Cancers:
o Any pertinent abdominal or pelvic imaging
o If metastatic disease present, send supporting documentation for
metastatic locations.
o Supporting documentation for recurrence if suspected

Additional information needed for pelvic masses suspicious for invasive
cancer
o Cat Scan or Ultrasound confirming mass

o BRCA results
o Any abdominal or pelvic imaging done
o CA 125
o Any surgical reports related to BRCA results (mastectomy/oophorectomy)
PLEASE SEND LAST PAP SMEAR IF AVAILABLE FOR ALL REFERRALS
DO NOT ASK FOR PAST MEDICAL HISTORY
Revised May 2015
Pg.34
Specialty Clinics
Hematology
Scope


To provide specialty expertise in the evaluation and management of blood
disorders beyond the scope of primary care physicians.
To prioritize limited availability to patients with malignancies or complex
hematologic disorders






Persistent, severe anemia after complete evaluation and treatment
Severe and/or clinically significant
o thrombocytopenia
o thrombocytosis
o leukopenia
o leukocytosis
Monoclonal gammopathy
Sickle Cell disease
Hypercoagulable state
Bleeding disorder






Completed referral form
Patient demographics
Current medication list and co-morbidities or problem list
Two most recent provider notes
Recent pertinent labs (See worksheet by diagnosis, drawn within the past 6
months, substantiating the disorder. Please send actual lab results not hand
written flow sheets.)
If previously treated by a Hematologist, send all hematology notes and previous
treatment records.
Additional information needed from previous 6 months (IF APPLICABLE)





Notes from all consultants (inpatient and outpatient)
Discharge summaries from relevant hospitalizations
All operative reports
Diagnostic procedure reports (endoscopy, bronchoscopy, biopsies)
All radiology reports
Revised May 2015
Pg.35
Specialty Clinics
Hematology Referral Worksheet

Persistent, severe anemia after complete evaluation and treatment
o Three consecutive CBC’s within the last year at least 1 month apart, most
recent within 1 month of referral, with hemoglobin less than 10.0
o TIBC, Ferritin, Serum Iron, B12 level, Folate level, TSH
o Iron deficiency is not appropriate for referral unless a complete GI
evaluation has been performed (colonoscopy and upper endoscopy)
o Anemia of renal insufficiency should be treated by nephrologist and is not
appropriate for referral

Thrombocytosis
recent within 1 month of referral
o Persistent platelet count > 600
o Peripheral Smear
o Iron deficiency has been ruled out

Thrombocytopenia
o Persistent platelet count < 100, or two platelet counts < 50
o 1 CBC in citrated (blue top) tube to evaluate for clumping

Leukopenia
o Persistent absolute neutrophil count less than 1500
o Lymphopenia is not appropriate for referral

Leukocytosis
o Physician documentation excluding infection
o Persistent absolute neutrophil count > 20,000
o Persistent absolute lymphocyte count > 10,000

Monoclonal gammopathy
o Serum protein electrophoresis (SPEP)
o Serum immunofixation
o Urine protein electrophoresis
o CBC, CMP
Pg.36
Specialty Clinics

Sickle Cell disease
o Hemoglobin electrophoresis documenting diagnosis

Hypercoagulable state (high risk thrombo-embolic event: DVT, PE, or
atypical arterial event)
o All radiology reports documenting thrombosis
o Coumadin flowsheets if applicable
o Specific question from referring physician, written on referral form, which
is to be addressed by consultant

Bleeding disorder
o Documentation of clinically significant bleeding
o All related labs
Revised May 2015
Pg.37
Specialty Clinics
Neurology Clinic
Scope


Neurology consultation
Follow-up of complex neurological patients









Central Nervous System Diseases
Parkinson's Disease
Multiple Sclerosis
Epilepsy not stable on a single medication (do not refer if seizure free ≥ 1 year)—
must have current EEG within 6 months of appointment ((((MD to review)))
Gait Disturbance
Tremors that have not responded to trial of at least one medication
Migraines persistent despite at least one prophylactic medication
Back Pain—must have radicular signs and symptoms
Peripheral Neuropathy (for suspected Carpal Tunnel Syndrome please use EMG
referral form)









Disability Evaluations
Patients with suspected Carpal Tunnel Syndrome (please use EMG referral form)
Back pain with positive MRI without radicular signs/symptoms
Chronic Non-specific Pain (Complex Regional Pain Syndrome, Fibromyalgia, etc)
Patients needing Pain Management
Bell’s Palsy unless recurrent
Patients with known Neurosurgery Needs (refer directly to Neurosurgery)
Lime Disease
Please Note: Appointments for EMGs are scheduled internally only




referred.
Pg.38
Specialty Clinics


Previous diagnostic evaluations, including any head imaging
Previous subspecialty evaluation
Revised May 2015
Note: Neuro Epilepsy schedule comes from Liz Wedberg, NP
Pg.39
Specialty Clinics
Neurology Clinic Worksheet
Back Pain (acute only with no neurological signs)
 Problem list and problem list
 MRI
Carpal Tunnel Syndrome
 EMG Referral Form
Seizures (do not refer if seizure free for 1 year)
 Medication List and Problem list
 EEG (within the last 6 months)
 Anticonvulsant levels
Parkinson’s Disease
 Medication list and problem list
Migraines (that have failed at least one prophylactic med)
 Problem list and medication list.
Multiple Sclerosis
Gait Disturbances
 Problem list and medication list
Peripheral Neuropathy
 Problem list and medication list
 Fasting glucose, B12, folate, TSH, ANA, CK, Sjogren, Viral hepatitis panel, HIV if
indicated, immunoelectrophoresis with fixation
Pg.40
Specialty Clinics
Tremors (that have not responded to at least one drug trial)
Memory loss




Problem list and medication list.
MRI brain
TSH, B12, RPR
EEG
Revised May 2015
Pg.41
Specialty Clinics
EMG Referral Form
Fax: (512) 380-7508
Patient Name / DOB: _______________________________________________________
Referring Clinic: ___________________________________________________________
Referring Provider: ________________________________________________________


Patients with suspected CTS without trial of appropriate conservative therapy
o Rest and wrist splinting for at least 1 month
Patients with chronic pain without new focal symptoms/signs:
o Fibromyalgia
o Complex Regional Pain Syndrome
Reason for Referral:
□
□
□
□
Numbness/Paresthesias/Tingling
Pain
Weakness/Fatigue
Increased CK, Possible Myopathy
Prior treatment: _____________________________________________________________
Prior EMG’s Date & Reason: ___________________________________________________
Other pertinent test results: ___________________________________________________
Extremity Affected:
□
□
□
□
□
Side:
□
□
□
□
Arm
Leg
Face/Tongue
Diaphragm/Trunk/Abdomen
Other: _________________
Pg. 42
Right
Left
Right + Left
Other: __________________
Specialty Clinics
Duration of Symptoms:
□
<4 weeks (it takes 3-6 weeks to fully develop EMG abnormalities after nerve injury;
schedule EMG on appropriate date, otherwise, repeat EMG may be necessary)
□
□
□
□
>4 weeks
>3 months
>6 months
>1 year
Other Medical Problems (i.e. – DM, HIV, Alcohol Abuse):
__________________________________________________________________
Physician Signature:
__________________________________________________________________
Revised May 2015
Pg. 43
Specialty Clinics
Oncology Clinic
Scope

To evaluate and treat patients who have been diagnosed with cancer or treated for
cancer.




Newly diagnosed cancers
Recurrent cancers
Patients receiving treatment for cancer
Patients needing follow-up for previously treated cancer
Do NOT refer the following patients:

Patients suspicious for malignancy but no biopsy (pathology) confirming cancer.
Biopsy Exception: Suspected Hepatocellular Carcinoma can be seen without a biopsy
if liver imaging is diagnostic of HCC and AFP is elevated




Thyroid cancer that has not spread (non-metastatic)
Prostate cancer that has not spread
Kidney cancer that has not spread
Skin Cancer (except metastatic melanoma)







Current referral form
Patient demographics
Current medication list and co-morbidities or problem list
Two most recent provider notes
Original pathology report confirming tissue diagnosis
If previously treated for cancer diagnosis, all oncology notes and treatment records
(chemotherapy flow sheets, operative notes)
If recurrence suspected, send supporting documentation (radiology, biopsies,
pathology)
Additional information needed related to cancer (IF APPLICABLE)




Notes from all consultants (inpatient and outpatient)
All operative reports
Diagnostic procedure reports (endoscopy, bronchoscopy)
All radiology reports
Pg. 44
Specialty Clinics
NOTE: If additional documentation or testing is required, a request will be FAXED back to the
referring clinic outlining the specific data needed. If the referral is incomplete or
seems inappropriate, the MD will be consulted, and his recommendations will be
stated on the form.
Revised May 2015
Pg. 45
Specialty Clinics
Orthopedic Clinic
Scope:

To provide consultation and orthopedic care for orthopedic problems which are unable to
be managed in outlying primary care clinics. Surgery may be arranged as indicated.









Musculoskeletal complaints including problems involving joints, tendons and muscles after
appropriate screening and adequate conservative care in the primary clinics
Chronic arthritis
Chronic tendonitis
Ganglion cyst
Arthralgia
Carpal tunnel (need EMG report)
Achilles tendon mass
Trigger finger (no xray needed)
Acute worsening arthritis








Acute closed fractures verified by x-ray (refer to Cast Clinic)
Acute infections or injuries (send to ER)
Neck pain and injuries (refer to Neurology Clinic)
Foot problems (refer to Foot Clinic)
Pediatric patients age 17 and under (refer to DCMC Ortho Clinic)
Patients needing prostheses
Acute or chronic low back pain
Back, feet or hand problems









Most recent progress note describing condition for which patient is being referred.
Imaging of involved anatomic structure
Lab/Imaging results can be more than 6 months but less than 1 year
Specific statement of concern or question to be answered regarding orthopedic complaint
Description, including time and duration, of conservative treatment
Relevant lab data
Revised May 2015
Pg. 46
Specialty Clinics
Pulmonary Clinic
Scope:

Evaluate patients with pulmonary disease beyond the scope of internal medicine and
family practice.







Steroid dependent / difficulty with controlling asthma
Lung mass
Interstitial lung disease
Sleep apnea—must have current sleep studies (within 3 months of appointment)
Newly diagnosed COPD
Unstable COPD
Emphysema



Stable/chronic low-level COPD (chronic obstructive pulmonary disease)
Asthma (send to Asthma clinic)
Pediatric patients








Current Chest X-ray (within the past 3 months) and old films if available
Copy of prior work-up including any pulmonary function tests, CT scans, labs, etc.
Results of any skin tests performed elsewhere (with dates & techniques).
Current Pulmonary Function Tests (within 3 months of appointment)
Revised May 2015
Pg. 47
Specialty Clinics
Renal/Hypertension Clinic
Scope

Evaluate and treat patients with renal insufficiency, significant proteinuria, past renal
transplant, SLE with possible nephropathy, and refractory hypertension.





Renal Insufficiency (men Cr ≥ 1.4, women Cr ≥ 1.2 or SLE with any increase)
Proteinuria ≥ 500mg/day (urine protein/urine creatinine ratio ≥ 0.5)
Uncontrolled Hypertension (persistent SBP ≥ 160 despite compliance with 3 or more
antihypertensive medications)
Renal Transplant
SLE with abnormal urinalysis or increased creatinine




Kidney stones (refer to Urology Clinic.)
Hematuria with normal renal function and no proteinuria (refer to Urology Clinic)
Proteinuria on dipstick alone (must have qualitative urine protein/urine creatinine ratio ≥
0.5)
Pediatric patients (age<18)








Labs need to be within 1 month at the time of referral
Renal ultrasound need to be within last 6 months
Retinal exam need to be within last 2 years
For Hospital and ER follow up, lab work 48 hours before appointment date
Revised May 2015
Pg. 48
Specialty Clinics
Renal/Hypertension Clinic Worksheet

Increased Creatinine
o CMP
o CBC
o Urinalysis with micro
o Renal Ultrasound (with post-void residual if age ≥ 50 or diabetic)
o If diabetic, need Hbg A1C and ophthalmic exam results with referral papers

Proteinuria
o
o
o
o

Hypertension
o
o
o
o
o

CMP
Urinalysis with micro
Urine protein/urine creatinine ratio
If diabetic, need Hbg A1C and ophthalmic exam results sent before renal appointment
CMP
Complete urinalysis
Renal Ultrasound if abnormal creatinine
Echocardiogram if available
Past medication trials
Renal Transplant
o
Immunosuppressive (cyclosporine, prograf, or cellcept) trough level taken 15 minutes
before medication dose
o CMP
o CBC

SLE
o CMP
o CBC
o Urinalysis with micro
o Urine protein/urine creatinine ratio
o Renal Ultrasound
Revised May 2015
Pg. 49
Specialty Clinics
Rheumatology Clinic
Scope:

To provide consultations at a subspecialty level in rheumatology.









(+)RF, (+)ANA titer =/> 1/160, (+) CCP
Rheumatoid Arthritis
Systemic Lupus Erythematosis
Gout
Ankylosing Spondylitis
Reiter’s Syndrome
Psoriatic Arthritis
Scleroderma
Muscle Diseases
o Polymyositis
o Dermatomyositis




Osteoarthritis
Fibromyalgia
Chronic Pain
Migraines





Recent pertinent lab (Complete lab profile, drawn within the past month, substantiating the
disorder. Please send lab flow sheets if they exist.)
Need CBC, CMP, Urinalysis, ESR, RF, ANA, CCP

Recent pertinent scans or X-rays
Revised May 2015
Pg. 50
Specialty Clinics
Rheumatology Clinic Worksheet
o
+ANA (R/O SLE or Lupus-like syndrome) & Connective Tissue Disease
o ANA Panel with ANA titer =/> 1/160
o Anticardiolipins,
o lupus anticoagulant
o ESR
o CBC
o CPK
o Beta 2 Glycoprotein
o Hepatitis Panel
o
+RF
o Anti CCP ab
o Hepatitis screening panel
o Serum immunofixation
o Bilateral wrist and hand films
o ANA Panel
o Anticardiolipins,
o lupus anticoagulant
o ESR
o CBC
o CPK
o *Negative Quantiferon TB or documented treatment of TB or documented negative PPD
o
Gout
o Joint fluid crystal results
o Uric acid level, CBC, CMP
o List of Medications
o Past Medical history
o
Ankylosing Spondylitis (spondyloarthropathy)
o SI joint films (2 views)
o HLAB 27 (Lab)
o
Sclerdoderma
o ANA Panel with ANA titer
o CPK
o Chest Xray
o Barium swallow
Pg. 51
Specialty Clinics
o Hep screening panel
o
Muscle Diseases
o Polynyositis
o Dermatomyositis
o CPK
o ESR
o Chest Xray
o Barium swallow
o
Psoriatic Arthritis
o Anti CCP ab
o ANA Panel
o UA
o CBC
o CMP
o ESR
o Hepatitis panel
*Only needed if patient has a history of positive TB test
Revised May 2015
Pg. 52
Specialty Clinics
Surgery Clinic
Scope



Seeing referrals from outlying clinics
Seeing referrals from other Brackenridge outpatient clinics
Follow-up of surgical and trauma patients
Appropriate patients for referral include: (any referrals outside this list will need to be
Pre-approved by the surgeon) *(If suspicious for malignancy refer to Surgical
Oncology)*


























Any hospital follow-up from general / trauma surgical service
* Abdominal mass
Ventral hernia / Incisional hernia**
Umbilical hernia / mass**
Inguinal hernia / mass**
Groin hernia / mass**
Thyroid mass / tumor / nodule / goiter (Team B)
Parathyroid hyperplasia / nodule / adenoma (Team B)
Lymph node biopsy / lymphadenopathy (((ASK MD IF IMAGING IS REQUIRED)))
*Pancreatic cyst / pseudocyst / mass / tumor / nodule
Splenomegaly
*Liver / hepatic mass / tumor / nodule
Gallstones / gallbladder / cholecystitis / biliary colic
*Stomach mass / tumor / nodule / ulcer
*Colon mass / tumor / nodule
Bowel obstruction
*Rectal mass / tumor / nodule / pain
Anal fissure / abscess
Guaiac / hemoccult positive / blood in stool (no colon screenings; limit 2
colon evals per day).
Diverticulosis / diverticulitis
Appendicitis
Hemorrhoids
Hidradenitis
Melanoma
Port-a-cath placement / removal / chemotherapy access
Pilonidal cyst / abscess – any size, no xray
Pg. 53
Specialty Clinics













Small lipomas, cysts, or skin lesions less than 4 cm (Refer to Derm)
GI bleeding which has not had H/H, stool guaiac
Vague abdominal pain
Breast Masses/Breast Disease (Refer to Shivers Center Breast Clinic)
Testicular Masses
Pediatric patients
Screening Colonoscopy (((ASK MD)))
Patient requesting cosmetic surgery evaluation
Cancer (Refer to Shivers Center)
Varicose Veins
Hyperhydrosis
Hydrocele – refer to Urology
Cystocele – refer to Urogyn








Include H&H and stool Guaiac if referring for GI bleeding
Does referring physician wish patient to return after consult or desire surgical
team to manage the problem patient is referred for
Study results indicating need for surgery
Pertinent X-ray films and reports
Revised May 2015
Pg. 54
Specialty Clinics
Urology Clinic
Scope:

Urology care for adults.








Cancers of urinary tract (kidney, bladder, prostate, testicular)
Obstructing kidney stones or stones > 1 cm (need non contrast CT prior)
Hematuria (CT/IVP and urine cytology prior) document x 2 with micro. UA
Urinary retention (after failed alpha blocker and voiding trial)
Elevated PSA (confirmed with repeat value)
PCKD without renal failure
Peyronies
Phimosis
















Proteinuria (Refer to Renal Clinic)
Skin rashes in genital area
Acute UTI's
Circumcisions (elective)
Vasectomy or reversals
Infertility
Cystocele in women (Urogyn)
PCKD with renal failure (Renal Clinic)
Erectile Dysfunction
Urinary incontinence for women (Urogyn)
Sexual Dysfunction
BPH
Chronic testicular pain
Hydrocele – unless patient is having persistent pain for 2-3 months
Urinary incontinence for men


Completed referral form, problem list, and medication list
Urinalysis and any other current, pertinent lab results. (Labs should be less than 3
months)
Pg. 55

Specialty Clinics
Pertinent X-ray films (CT or US) and reports (should be less than 3 months)
Revised May 2015
Pg. 56
Specialty Clinics
Urology Clinic Worksheet

UTI – chronic or reoccurring only:
o Send urine culture results – recent to appointment <3 months
o IVP

Hematuria and Micro hematuria:
o IVP (Priority)(or CT scan abdominal /pelvis with contrast), microscopic urinalysis (at least
2) documenting abnormal # of blood cells and absence of active infection
o Urine Cytology

Urinary Frequency:
 UA
 Urine Culture
 PSA required for men

Kidney Stones:
o IVP or CT/abd/pelvis

Scrotal/Testicular Mass/Testicular Pain:
o Scrotal Ultrasound

Prostate Problem:
o PSA
o Urine culture
Note:
If unable to do IVP (eg: allergic to contrast) get a Renal (abdominal) Ultrasound
Revised May 2015
Pg. 57
Specialty Clinics
FAX Transmittal — Specialty Clinics — MAP Patients
Paul Bass Clinic — FAX #324-8074/324-8072
Shivers — Breast/Hem/Onc Clinic — FAX #324-7972/324-7138
Sub-specialty Clinic — FAX #324-7857/324-8203
From Clinic:
Fax:
Contact Name:
Contact Phone:
Pages (including fax transmittal):
Re:
NOTE: Appointment information will be faxed to the PCP clinic within 72 business hours of receiving a completed
referral with all pertinent documentation. The PCP clinic is responsible for notifying the patient of the specialty
appointment.
Comments:
The information contained in this facsimile message is legally privileged and confidential
information intended only for the use of the entity named above. If the reader of this transmission is
not the intended recipient, you are hereby notified that any dissemination, distribution or copying of
this transmission is strictly prohibited.
If you received this transmission in error, please
immediately notify us by telephone to arrange for return of the original documents.
Pg. 58
Specialty Clinics
Seton Imaging and Radiology — Required Labs
Labs required prior to scheduled test:
1. ULTRASOUND
a. Labs: PT, PTT CBC w/platelets, total INR
i. US Guided Breast localization
ii. US Breast tissue specimen
iii. US Biospy Abdomen
iv. US Guided Biopsy Breast
v. US Biopsy Lung/mediastinum
vi. US guided amniocentesis
vii. US guided Biopsy
viii. US Guided Biopsy Liver
ix. US Guided Biopsy Renal
x. US Guided Cyst Aspiration
xi. US Guided paracentesis
xii. US guided Percutaneous drainage
xiii. US guided RAD SEEDS
xiv. US guide THER FLD
xv. US guided thoracentesis
xvi. US mammography core biopsy left
xvii. US mammography core biopsy right
xviii. US Mammo cyst additional left/right
xix. US Mammo cyst aspiration
xx. US mammo needle placement left/right
xxi. US Sed IV/IM/NHL
xxii. US sed ORL/REC/NA
2. FLUOROSCOPY
a. LABS: PT/PTT CBC w/platelets and total INR
i. Lumbar puncture
ii. C2 puncture w/injection (BUN, Creat.)
iii. C2 puncture
iv. Flouro needle biopsy
(ALL FLUORO EXAMS WITH IV CONTRAST REQUIRES BUN AND CREATININE)
Pg. 59
Specialty Clinics
Seton Imaging and Radiology — Required Labs ( c o n t i n u e d )
3. CAT SCAN
a. Labs: PT/PTT, CBC w/platelets and total INR, BUN and CREAT
i. CT Biopsy- Abdomen
ii. CT Biopsy Bone
iii. CT biopsy Lung Left
iv. CT Biopsy Lung Right
v. CT Biopsy Liver
vi. CT Biopsy Pancreas
vii. CT Biopsy Pleura left
viii. CT Biopsy Pleura right
ix. CT Biopsy Renal left
x. CT Biopsy Renal right
xi. CT Cervical Puncture
xii. CT C1/C2 Puncture
xiii. CT Drainage Lung left
xiv. CT Drainage Lunt right
xv. CT Drainage liver
xvi. CT drainage pancreas
xvii. CT drainage peritoneal
xviii. CT drainage retroperitoneal abscess
xix. CT drainage renal left
xx. CT drainage renal right
xxi. CT drainage Subdiaphragm/subphrenic
xxii. CT Guided Cyst aspiration
xxiii. CT guided lumb kypho
xxiv. CT guided lumb vert
xxv. CT guide needle biopsy
xxvi. CT guide percutaneous drainage
xxvii. CT guide RFA
xxviii. CT guide RTF placement
xxix. CT injection Lumbar or Thoracic Spine
(BUN and CREATININE REQUIRED FOR ALL CT EXAMS WITH IV CONTRAST)
4. MRI
a. Labs: PT/PTT CBC w/platelets Total INR
i. MR guided needle placement
(All MRI EXAMS WITH IV CONTRAST REQUIRE BUN AND CREATININE)
5. NUCLEAR MEDICINE
a. Labs: PT, PTT, CBC w/platelets INR
i. NM lymphoscintgraph — breast(labs needed for surgery
Pg. 60
Specialty Clinics
Diagnostic Order Forms
See attached order forms for the following:
□ Audiology Testing
o Phone 324-9999 x 77826
o Fax 380-7508
□ Cardiology Electroneurodiagnostic Testing
o Phone 324-1375
o Fax 380-4263
□ Physical Therapy (OP Wound Care; OP OT Low Vision; OP MBS)
o Phone 324-7600
o Fax 324-7566
□ Pulmonary Function Test
□ Pulmonary Function Lab
o Phone 324-1375
o Fax 380-4263
Pg. 61
Specialty Clinics
Adult Audiology Request Form
Phone: 512-324-9999 x77826
Fax: 512-380-7508
Please COMPLETE this updated Physician Order form for ADULT audiology referrals
 Please include a demographics sheet,
& please encourage your patients to show up for their appointments
Requesting:
 Basic Audio
 Other___________________________________
THIS VISIT
FROM:__________________________________
 REQUIRES AUTHORIZATION
PHONE:_________________________________
Authorization #:
FAX:____________________________________
 DOES NOT REQUIRE AUTHORIZATION
***Referrals without a fax number will be rejected***
(Must be)
Full Name of Referring Physician:_______________________________________M.D. or D.O.
Name of Patient’s PCP:________________________________________________
Diagnosis/Reason for Referral (Check ALL that apply):
 Decreased hearing
 Unilateral/asymmetric loss
 Otitis/inflammation of ear
 TM perforation
Pg. 62
 Speech delay
 Tinnitus
Specialty Clinics
 Sudden hearing loss
 Discharge from ear
 Vertigo/dizziness
 Ear Pain
 Adverse affects of medication
 Other_______________________
Patient name:___________________________________________Date of birth __ __ / __ __ / __ __
Contact Numbers:_____________________________________________________________________
Insurance Company:_______________________________________Group or ID#:_________________

_____________________________________Date:__________
Physician Signature and Date Required
Pg. 63
Specialty Clinics
Pg. 64
Specialty Clinics
Pg. 65
Specialty Clinics
Pg. 66
Specialty Clinics
Pg. 67
Specialty Clinics
Directions to Paul Bass Clinic:
Directions from the Clinical Education Center (CEC) parking garage:
(ONLY pink map card holders can receive a parking validation)
□ The parking garage is located on the access road of 1-35 South, on the corner of 15th street
□ Park in the parking garage and enter through the main entrance of the Clinical Education Center
(CEC)
□ Walk toward the right, passing the first set of elevators, and then follow the signs of the Paul
Bass Clinic until the second set of elevators.
□ Take the elevators down to Lower Level (LL).
□ Make a right when you get out of the elevators and follow the signs to the Paul Bass Clinic.
Directions from the Brackenridge Hospital parking garage:
(ONLY pink map card holders can receive a parking validation)
□
□
□
□
The parking garage is located on the corner of 15th Street and Red River.
Take the parking garage elevator to Level 4.
Follow the hallway to the entrance of Brackenridge Hospital.
Pass the first set of elevators, and then follow the long hallway until you reach the second set of
elevators.
□ Take the elevators down of Lower Level (LL).
□ Make a right when you get out of the elevators and follow the signs to the Paul Bass Clinic.
Directions from the Capital Metro bus stop: 10 & 20
□ Enter the hospital through the main entrance located on the 1st floor.
□ Pass the first set of elevators, pass the cafeteria, and then follow the long hallway until you get to the
second set of elevators.
□ Take the elevators down to the Lower Level (LL).
□ Turn to the right when you get off the elevator and follow the signs to the Paul Bass Clinic.
Directions from the Capital Metro bus stop: 37
□ Get off the bus on the corner of Red River and 15th Street.
□ Enter the hospital through the main entrance located on the 1st floor.
□ Pass the first set of elevators, pass the cafeteria, and then follow the long hallway until you get to the
second set of elevators.
□ Take the elevators down to the Lower Level (LL).
□ Turn to the right when you get off the elevator and follow the signs to the Paul Bass Clinic.
Pg. 68
Specialty Clinics
Instrucciones si entre en el estacionamiento de CEC:
(SOLAMENTE los recipientes de la tarjeta de MAP rosada pueden recibir la validación del estacionamiento)
□ El estacionamiento está localizado en la carretera de acceso de 1-35 Sur, en la esquina de Calle 15.
□ Estaciónese en el estacionamiento y entre en la entrada mayor del Centro de Educación Clinica (CEC).
□ Camine hacia la derecha, pase los primeros elevadores, luego siga los signos de la Clinica de Paul Bass
hasta los segundos elevadores.
□ Tome los elevadores abajo al Piso LL.
□ Dase una vuelta a la derecha cuando salga del elevador y siga los signos hacia la Clinica de Paul Bass.
Instrucciones si entre en el estacionamiento del Hospital de Brackenridge:
(SOLAMENTE los recipientes de la tarjeta de MAP rosada pueden recibir la validación del estacionamiento)
□
□
□
□
□
□
El estacionamiento está localizado en la esquina de Calle 15 y Red River.
Tome el elevador del estacionamiento al Nivel 4.
Siga el vestibulo hacia la entrada del hospital de Brackenridge.
Pase los primeros elevadores y siga el largo vestibulo hasta los segundos elevadores.
Tome los elevadores abajo al Piso LL.
Dase una vuelta a la derecha cuando salga del elevador y siga los signos hacia la Clinica de Paul Bass.
Instrucciones desde la parada de Autobñs: 10 y 20
□ Entre en el hospital por la entrada mayor localizada en el primer piso.
□ Pase los primeros elevadores, pase la cafeteria, luego siga el largo vestibulo hasta los segundos
elevadores.
Instrucciones desde la parada de Autobñs: 37
□ Salga del autobüs en la esquina de Red River y Calle 15.
□ Entre en el hospital por la entrada mayor localizada en el primer piso.
□ Pase los primeros elevadores, pase la cafeteria, luego siga el largo vestibulo hasta los segundos
elevadores.
Pg. 69
Pg. 70
Brackenridge
Specialty Clinics
University Medical Center Brackenridge Specialty Clinics
REFERRAL FORM
This form is intended to assure prompt communication back to requesting providers. Please Fax
referral form and supporting documents to (512)380-7508.
*Check Specialty Preference (Check one):


















Asthma
Cardiology
Cast
Dermatology
Endocrinology
Nephrology















Neurology
Ophthalmology
Orthopedic
Podiatry
Gastroenterology















Pulmonology
Rheumatology
Surgery
ENT
Urology


 First Available ____________


 No Preference ____________
*Patient Name:
*Primary Language:
_______________________________________________________________________________________
*Telephone: ___________________ *Alternative Number: ___________________ *DOB: _______________
Address: _______________________________ City: ______________ State: ________ Zip: _____________
*Insurance Information (Plan Name): ________________*Policy number: ___________*Exp Date_________
Authorization number (if applicable): ______________________ Exp Date: _____________________________
Pg. 71
*Referring Clinic: __________________*Referring Physician: _____________________*Date: ___________
*Telephone: ________________ *Fax: _________________*Submitted by: __________________________
Reason for the Referral (please include appropriate diagnosis and attach pertinent clinical/progress notes or provide clinical
narrative, including duration of problem, types of treatment, pertinent physical findings, pertinent testing results, diagnostic
work-ups, including lab and imaging supporting documents):
Overbook Request Information (Please specify below in detail reason for overbook):
(For CommUnityCare Use) Appointment date:
Time:
* In order to process request all required fields must be completed
NOTICE OF CONFIDENTIALITY – This document is intended solely for the use of the individual identity to which it is addressed and may contain
information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this notice is not the intended recipient or
individual responsible for delivering the message to the intended recipient, you are hereby advised that any dissemination, distribution or copying of this
information is strictly prohibited. If you have received this communication in error, please advise us immediately by telephone and destroy these papers
Pg. 72
Pg. 73
Pg. 74
Pg. 75
Pg. 76
9. PHARMACY SERVICES
PHARMACY SERVICES
Pharmacy Co-payments
MAP Network Pharmacies
MAP Formulary
Non-Formulary Medication Request
Patient Assistance Programs (PAP) Medication Interim Fill
MAP Pharmacy Hotline
PHARMACY SERVICES
Pharmacy Co-payments
GROUP
CBRACKFQ
CBRACKFQ
PLAN
CBRACKFQ
CPENDSSI
Formulary Drug
$7 co-pay for 1-30 day supply or
$20 co-pay for 31-90* day supply
or
$0 co-pay if noted on MAP card
* 90 day supply on selected drugs
only
Non-Formulary Drug
$10 co-pay
or
$7 co-pay for 1-30 day supply
or
$20 co-pay for 31-90* day supply
or
* 90 day supply on selected drugs
only
$10 co-pay
or
MAP Network Pharmacies
 See document entitled “MAP Network Pharmacies.”
MAP Formulary
 See document entitled “MAP Formulary.”
Non-Formulary Medication Request
Submit a Medication Override Request Form if the patient cannot tolerate generic or
formulary medication and requires a medication that is nonformulary.
 See document entitled “Medication Override Request Form.”
Pharmacy Services Page 1 of 2
Revised 08-01-2011
Patient Assistance Programs (PAP) Medications
If a patient is eligible for Patient Assistance Program (PAP) medications, Provider should:
a. submit PAP paperwork on behalf of the patient and
b. submit a Medication Override Request Form for consideration of an interim fill.
 See document entitled “Medication Override Request Form.”
MAP Pharmacy Hotline:
Telephone: (512) 978-8139
Fax: (512) 901-9763
Call the Pharmacy Hotline if you have questions or need copies of MAP
pharmacy documents.
Please call MAP at
(512) 978‐8130
Drug Formulary 2/01/2015
Therapeu
tic Class
Analgesic
s/Antipyre
tics
Therapeutic Sub-Class
Trade Name
Generic Name
Cove
rage
Not
appro
ved
Type
Comments
lidocaine 5%
Strength &
Quantities
700mg/patch #30
Anesthetic, local
Lidoderm Patch
Nonformula
ry
Celebrex
celecoxib
50, 100, 200, 400mg
Appr
oved
Central
Pharma
cy
Available to
CommUnityCare
prescribers but
restricted to DX of
Postherpetic
Neuralgia. Email
*PAP for override.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Analgesic
s/Antipyre
tics
COX-2 Inhibitor, Systemic
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
NSAID, Systemic
Anaprox DS
naproxen sodium
275, 550mg
Appr
oved
NSAID, Systemic
Feldene
piroxicam
10, 20mg
Appr
oved
Retail
Networ
k
Central
Pharma
cy
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
NSAID, Systemic
Indocin
indomethacin
25, 50, 75mg
Appr
oved
NSAID, Systemic
Ketoprofen
ketoprofen
50, 75mg
Appr
oved
NSAID, Systemic
Ketoprofen ER
ketoprofen
200mg
Appr
oved
NSAID, Systemic
Lodine (capsule)
etodolac
400, 500mg
(capsule)
Appr
oved
NSAID, Systemic
Lodine (tablet)
etodolac
200, 300mg (tablet)
Appr
oved
NSAID, Systemic
Lodine XL
etodolac extendedrelease
400, 500, 600mg
(tablet)
Appr
oved
NSAID, Systemic
Mobic
meloxicam
7.5, 15mg
Appr
oved
NSAID, Systemic
Motrin
ibuprofen
400, 600, 800mg
Appr
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
oved
NSAID, Systemic
Naprosyn
naproxen
250, 375, 500mg
Appr
oved
NSAID, Systemic
Relafen
nabumetone
500, 750mg
Appr
oved
NSAID, Systemic
Vimovo
naproxen/esomeprazole
375/20, 500/20mg
Appr
oved
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
NSAID, Systemic
Voltaren
25, 50, 75mg (tablet)
Appr
oved
NSAID, Systemic
Voltaren XR
diclofenac sodium
delayed-release
(enteric-coated)
diclofenac sodium
extended-release
100mg
Appr
oved
NSAID, Systemic / Anti-ulcer
Agent
Arthrotec
diclofenac sodium
delayedrelease/misoprostol
50mg/200mcg,
75mg/200mcg
(tablet)
Appr
oved
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
NSAID, Topical
Voltaren 1% gel
diclofenac sodium 1%
100g
Appr
oved
Opiate Agonists
Duragesic
fentanyl patch (C-II)
12, 25, 50, 75,
100mcg/hr
Opiate Agonists, Systemic
Acetminophen/C
odeine Elixir
acetaminophen/codeine
120mg-12mg/5ml
Not
appro
ved
Appr
oved
Dilaudid
hydromorphone (C-II)
2, 4, 8mg
Appr
oved
Dolophine
methadone (C-II)
5, 10, 40mg
Appr
oved
Endocet
oxycodone/acetaminoph
en (C-II)
10/325mg
Appr
oved
Morphine Sulfate
morphine sulfate (C-II)
15, 30mg (tablet)
Appr
oved
MS Contin
morphine extendedrelease (C-II)
15, 30, 60mg
Appr
oved
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
Analgesic
s/Antipyre
tics
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
Norco
hydrocodone/
acetaminophen (C-II)
5/325, 7.5/325,
10/325mg
Appr
oved
OxyIR,
Roxicodone
oxycodone HCL (C-II)
5mg
Appr
oved
Percocet
oxycodone/
acetaminophen (C-II)
5/325, 7.5/325
Appr
oved
Percodan
oxycodone/aspirin (CII)
4.88/325mg
Appr
oved
Roxanol
morphine sulfate (C-II)
10mg/5mL,
20mg/5ml (solution)
Appr
oved
Tylenol #2
300mg/15mg
Appr
oved
Tylenol #3
300mg/30mg
Appr
oved
Tylenol #4
300mg/60mg
Appr
oved
Ultracet
tramadol/acetaminophe
n
37.5mg/325mg
Appr
oved
Ultram
tramadol
50mg
Appr
oved
Vicoprofen
hydrocodone/ibuprofen
(C-II)
7.5/200mg
Appr
oved
Salicylates
Salsalate
salsalate
500, 750mg
Appr
oved
Alpha-Glucosidase Inhibitor
Glyset
miglitol
25, 50, 100mg
Alpha-Glucosidase Inhibitor
Precose
acarbose
50,100mg
Amylinomimetic
Symlin
pramlintide
60 (1.5mL), 120
(2.7mL)
Not
appro
ved
Not
appro
ved
Appr
oved
AntiDiabetic
Agents
Anti-
Antihypoglycemic
Glucagon
Emergency Kit
glucagon injection
1mg/ml
Appr
oved
Biguanide
Glucophage
metformin
500, 850, 1000mg
Appr
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
PAP
Central
Pharma
cy
Retail
Networ
k
Retail
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Diabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
oved
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Biguanide
Glucophage XR
metformin ER
500, 750mg
Appr
oved
Biguanide/Sulfonylurea
Glucovance
glyburide/metformin
1.25/250, 2.5/500,
5/500mg
Appr
oved
Biguanide/Sulfonylurea
Metaglip
glipizide/metformin
2.5/250, 2.5/500,
5/500mg
Appr
oved
DDP-4 Inhibitor/Biguanide
Janumet
sitagliptin/metformin
50/500, 50/1000mg
Appr
oved
AntiDiabetic
Agents
Janumet XR
sitagliptin/metformin
ER
50/500, 50/1000,
100/1000mg
Appr
oved
Central
Pharma
cy
AntiDiabetic
Agents
Kombiglyze XR
saxagliptin/metformin
ER
2.5/1000, 5/500,
5/1000mg
Appr
oved
Central
Pharma
cy
AntiDiabetic
Agents
DPP-4 agent
Januvia
sitagliptin
25, 50, 100mg
Appr
oved
Central
Pharma
cy
AntiDiabetic
Agents
DPP-4 agent
Onglyza
saxagliptin
2.5, 5mg
Appr
oved
Central
Pharma
cy
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
AntiDiabetic
Agents
Incretin Mimetic
Byetta
exenatide
5 (1.5mL), 10mcg
(2.4mL) pen
Appr
oved
Central
Pharma
cy
AntiDiabetic
Agents
Incretin mimetic
Victoza
liraglutide
3ml pen (6mg/ml)
Not
appro
ved
PAP
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
Insulin
Apidra
insulin, glulisine
10ml (vial)
PAP
Insulin
Apidra Solostar
insulin, glulisine
15ml (box)
PAP
Novolog preferred
Insulin
Humalog
insulin, lispro
10ml (vial)
Not
appro
ved
Not
appro
ved
Appr
oved
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Pt to wait on
arrival from PAP.
No interims
available.
Prescribe insulin
for rapid glucose
control.
Novolog preferred
Insulin
Humalog 50/50
Kwipen
insulin, lispro/lispro
protamine
15ml (box)
Appr
oved
Insulin
Humalog
Kwikpen
insulin, lispro
15ml (box)
Appr
oved
Insulin
Humalog Mix
50/50
protamine
10ml (vial)
Appr
oved
Insulin
Humalog Mix
75/25
protamine
10ml (vial)
Appr
oved
Insulin
Humalog Mix
75/25 Kwikpen
protamine
15ml (box)
Appr
oved
Insulin
Humulin 70/30
insulin, NPH/regular
10ml (vial)
Insulin
Humulin N
insulin, NPH
10ml (vial)
Insulin
Humulin R
insulin, regular
10ml (vial)
Insulin
Humulin R U500
insulin, regular
20ml (vial)
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
Nonformula
ry
Nonformula
ry
PAP
Prescribe Novolin
instead
Prescribe Novolin
instead
Prescribe Novolin
instead
Available to
CommUnityCare
prescribers, email
*PAP for override.
All other
prescribers must
enroll in PAP or
prescribe Novolin
AntiDiabetic
Agents
Insulin
Lantus
insulin, glargine
10ml (vial)
Not
appro
ved
PAP
AntiDiabetic
Agents
Insulin
Lantus Solostar
insulin, glargine
15ml (box)
Not
appro
ved
PAP
AntiDiabetic
Agents
Insulin
Levemir
insulin, detemir
10ml (vial)
Not
appro
ved
PAP
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
Anti-
Insulin
Novolin 70/30
insulin, NPH/regular
10ml (vial)
Appr
oved
Insulin
Novolin N
insulin, NPH
10ml (vial)
Appr
oved
Insulin
Novolin R
insulin, regular
10ml (vial)
Appr
oved
Insulin
Novolog
insulin, aspart
10ml (vial)
Appr
oved
Insulin
Novolog 70/30
insulin, aspart/aspart
protamine
10ml (vial)
Appr
oved
Insulin
Novolog 70/30
Flexpen
insulin, aspart/aspart
protamine
15ml (box)
Appr
oved
Insulin
Novolog Flexpen
insulin, aspart
15ml (box)
Appr
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Preferred insulin
for
CommUnityCare
prescribers. Email
*PAP for override.
All other
prescribers must
enroll in PAP or
use Novolin-N.
CommUnityCare
prescribers may
request override
for patients
receiving Lantus
Solostar prior to
August 2014. No
overrides for new
insulin starts.
Other prescribers
must enroll in
PAP or use
Novolin-N.
Preferred insulin
for
CommUnityCare
prescribers. Email
*PAP for override.
Other prescribers
must enroll in
PAP or use
Novolin-N.
Diabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
oved
Insulin, Supplies
Novofine Pen
Needles
insulin pen needles
30G 1/3"
Appr
oved
Insulin, Supplies
Novofine Pen
Needles
insulin pen needles
32G 1/4"
Appr
oved
Insulin, Supplies
Pen Needles
insulin pen needles
29G 1/2"
Appr
oved
Insulin, Supplies
Pen Needles
insulin pen needles
30G 5/16"
Appr
oved
Insulin, Supplies
Pen Needles
insulin pen needles
31G 1/4", 31G
3/16", 31G 5/16"
Appr
oved
Insulin, Supplies
Pen Needles
insulin pen needles
32G 5/32"
Appr
oved
Meglitinide
Prandin
repaglinide
0.5, 1, 2mg
Meglitinide
Starlix
nateglinide
60, 120mg
Not
appro
ved
Appr
oved
SGLT-2 antagonist
Farxiga
dapagliflozin
5, 10mg
Appr
oved
Sulfonylurea
Amaryl
glimepiride
1, 2, 4mg
Appr
oved
Sulfonylurea
Glucotrol
glipizide
5, 10mg
Appr
oved
Sulfonylurea
Glucotrol XL
glipizide XL
2.5, 5, 10mg
Appr
oved
Sulfonylurea
Micronase,
Diabeta
glyburide
1.25, 2.5, 5mg
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 0.3ml 29G
1/2"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 0.3ml 30G
1/2", 30G 5/16"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 0.3ml 31G
5/16"
Appr
oved
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
Starlix is preferred
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
AntiDiabetic
Agents
Antidote
Antihista
mines
Supplies
Insulin syringes
insulin syringes
U-100 0.5mL 28G
1/2"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 0.5mL 29G
1/2"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 0.5mL 30G
1/2", 30G 5/16"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 0.5mL 31G
5/16"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 1mL 28G
1/2"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 1mL 29G
1/2"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 1mL 30G
1/2", 30G 5/16"
Appr
oved
Supplies
Insulin syringes
insulin syringes
U-100 1mL 31G
5/16"
Appr
oved
Testing supplies
InControl
Codeless Test
Strips
Incontrol Lancets
test strips
50 strips/bottle
Appr
oved
lancets
28G
Appr
oved
Testing supplies
TRUEplus
Lancets
lancets
28G
Appr
oved
Testing supplies
TrueResult Blood
Glucose System
glucometer kit
1 kit
Appr
oved
Testing supplies
TrueTest normal
glucose control
control solution, normal
1 bottle
Appr
oved
Testing supplies
TrueTest Test
Strips
test strips
50 strips/bottle
Appr
oved
Thiazolidinedione
Actos
pioglitazone
15, 30, 45mg
Appr
oved
Alpha/Beta antagonist
Epipen
epinephrine
0.3mg auto injector
Appr
oved
Antihistamines, nasal
Astelin
azelastine
137mcg (30mL)
Appr
oved
Testing supplies
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Antihista
mines
Antihistamines, systemic
Atarax (syrup)
hydroxyzine HCL
(syrup)
10mg/5ml syrup
Appr
oved
Antihista
mines
Atarax (tablet)
hydroxyzine HCL
(tablet)
10, 25, 50mg tablet
Appr
oved
Antihista
mines
Claritin
loratadine
10mg
Appr
oved
Antihista
mines
Cyproheptadine
(syrup)
cyproheptadine (syrup)
2mg/5ml (syrup)
Appr
oved
Antihista
mines
Cyproheptadine
(tablet)
cyproheptadine (tablet)
4mg (tablet)
Appr
oved
Antihista
mines
Vistaril (capsule)
hydroxyzine pamoate
(capsule)
25, 50, 100mg
(capsule)
Appr
oved
Antihista
mines
Xyzal (solution)
levocetirizine (solution)
2.5mg/5ml (solution)
Appr
oved
Antihista
mines
Xyzal (tablet)
levocetirizine (tablet)
5mg (tablet)
Appr
oved
Antihista
mines
Zyrtec
cetirizine
10mg
Appr
oved
AntiInfectives
Anibiotic, Aminoglycosides
Neomycin
neomycin sulfate
500mg
Appr
oved
AntiInfectives
Anitbiotic, Furantoins
Furadantin
nitrofurantoin
25mg/5ml (240mL
suspension)
Appr
oved
AntiInfectives
Macrobid
nitrofurantoin
100mg capsule
Appr
oved
AntiInfectives
Macrodantin
nitrofurantoin
macrocrystal
50, 100mg capsule
Appr
oved
Anti-
Anitbiotic, Macrolides
Biaxin
clarithromycin
125/5mL,
Appr
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Infectives
(suspension)
(suspension)
250mg/5ml
oved
AntiInfectives
Biaxin (tablet)
clarithromycin
250, 500mg
Appr
oved
AntiInfectives
E.E.S.
(suspension)
erythromycin ethyl
succinate (suspension)
200mg/5mL,
400mg/5ml
Appr
oved
AntiInfectives
Ery-Tab
erythromycin base
(enteric-coated)
250, 333, 500mg
Appr
oved
AntiInfectives
Zithromax
(suspension)
azithromycin
(suspension)
100mg/5mL,
200mg/5mL
Appr
oved
AntiInfectives
Zithromax
(tablet)
azithromycin (tablet)
250mg tab; 500mg
tab
Appr
oved
AntiInfectives
Zithromax (TriPak)
azithromycin (Tri-Pak)
500mg (Tri-pak #3)
Appr
oved
AntiInfectives
Zithromax (ZPak)
azithromycin (Z-Pak)
250mg (Z-pak #6)
Appr
oved
AntiInfectives
Anthelmintics
Stromectol
ivermectin
3mg
AntiInfectives
Antibiotic, Cephalosporins
Ceftin (tablet)
cefuroxime (tablet)
250, 500mg
Not
appro
ved
Appr
oved
AntiInfectives
Cefzil
(suspension)
cefprozil (suspension)
250mg/5ml
Appr
oved
AntiInfectives
Cefzil (tablet)
cefprozil (tablet)
250, 500mg
Appr
oved
AntiInfectives
Keflex (capsule)
cephalexin (capsule)
250, 500mg
Appr
oved
AntiInfectives
Keflex
(suspension)
cephalexin (suspension)
250mg/5ml
Appr
oved
AntiInfectives
Keflex (tablet)
cephalexin (tablet)
250, 500mg
Appr
oved
AntiInfectives
Omnicef
(capsule)
cefdinir (capsule)
125mg/5ml,
250mg/5ml
Appr
oved
AntiInfectives
Omnicef
(suspension)
cefdinir (suspension)
300mg
Appr
oved
AntiInfectives
Antibiotic, Fluoroquinolones
Cipro
ciprofloxacin (tablet)
100, 250, 500,
750mg
Appr
oved
Anti-
Antibiotic, Fluoroquinolones
Levaquin
levofloxacin (tablet)
250, 500, 750mg,
Appr
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Permethrin
preferred for lice
Infectives
750mg
oved
AntiInfectives
Antibiotic, Macrolides
Combination
Pediazole
(suspension)
erythromycin/sulfisoxaz
ole (suspension)
200-600mg/5ml
200ml
Appr
oved
AntiInfectives
Antibiotic, Miscellaneous
agents
Cleocin
clindamycin
150, 300mg
Appr
oved
AntiInfectives
Antibiotic, Penicillins
Amoxil (capsule)
amoxicillin (capsule)
250mg, 500mg
Appr
oved
AntiInfectives
Amoxil
(suspension)
amoxicillin
(suspension)
Appr
oved
AntiInfectives
Amoxil (tablet)
amoxicillin (tablet)
125mg/5mL,
200mg/5mL,
250mg/5mL and
400mg/5mL
500mg, 875mg
AntiInfectives
Augmentin
(suspension)
amoxicillin/clavulanate
(suspension)
Appr
oved
AntiInfectives
Augmentin
(tablet)
amoxicillin/clavulanate
(tablet)
200-28.5mg/5mL,
250-62.5mg/5mL,
400-57mg/5mL,
600-42.9mg/5mL,
250-125mg, 500125mg, 875-125mg
AntiInfectives
Dynapen
dicloxacillin
250, 500mg
Appr
oved
AntiInfectives
Trimox
(suspension)
amoxicillin
(suspension)
Appr
oved
AntiInfectives
Trimox (tablet)
amoxicillin (tablet)
125mg/5mL,
200mg/5mL,
250mg/5mL and
400mg/5mL
500mg, 875mg
AntiInfectives
Veetids
(suspension)
penicillin V potassium
(suspension)
125/5mL,
250mg/5ml
Appr
oved
AntiInfectives
penicillin V potassium
(tablet)
250, 500mg
Appr
oved
AntiInfectives
Antibiotic, Sulfonamides
Veetids
(tablet/suspensio
n)
Azulfidine
sulfasalazine
500mg
Appr
oved
AntiInfectives
Antibiotic, Sulfonamides &
Sulfones
Septra
Suspension
sulfamethoxazole/trimet
hoprim (suspension)
200-40mg/5ml
100ml
Appr
oved
AntiInfectives
Antibiotic, Sulfonamides &
Sulfones
Septra, Septra DS
(tablet)
sulfamethoxazole/trimet
hoprim (tablet)
400/80mg,
800/160mg
Appr
oved
AntiInfectives
Antibiotic, Tetracyclines
Doxycycline
(capsule)
doxycycline;
doxycycline hyclate and
monohydrate (capsule)
20, 50, 75, 100,
150mg
Appr
oved
Appr
oved
Appr
oved
Appr
oved
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
AntiInfectives
Doxycycline
(suspension)
doxycycline;
monohydrate
(suspension)
doxycycline;
monohydrate (tablet)
25mg/5ml
Appr
oved
Retail
Networ
k
AntiInfectives
Doxycycline
(tablet)
20, 50, 75, 100,
150mg
Appr
oved
Retail
Networ
k
AntiInfectives
Minocin;
Dynacin
minocycline
50, 75, 100mg
Appr
oved
Anti-Fungals, Systemic
Diflucan
(suspension)
fluconazole
(suspension)
10mg/mL, 40mg/mL
Appr
oved
AntiInfectives
Diflucan (tablet)
fluconazole (tablet)
50, 100, 150, 200mg
Appr
oved
Antiinfectives
Grifulvin (tablet)
griseofulvin (tablet)
125, 250, 500mg
Appr
oved
AntiInfectives
Grifulvin V
(suspension)
griseofulvin microsize
(suspension)
125mg/5ml
Appr
oved
AntiInfectives
Gris-PEG (tablet)
griseofulvin
ultramicrosize (tablet)
125, 250mg
Appr
oved
AntiInfectives
Lamisil
terbinafine
250 mg
Appr
oved
AntiInfectives
Nystatin
(suspension)
nystatin (suspension)
100,000 units/ml
Appr
oved
AntiInfectives
Nystatin (tablet)
nystatin (tablet)
500,000 units
Appr
oved
AntiInfectives
Sporanox
itraconazole
100mg
AntiInfectives
Sporanox
(suspension)
itraconazole
(suspension)
10mg/mL
AntiInfectives
Antihelmintics
Albenza
albendazole
200mg
Not
appro
ved
Not
appro
ved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
AntiInfectives
AntiInfectives
Antimalarials
Plaquenil
hydroxychloroquine
200mg
Appr
oved
AntiInfectives
Antimalarials
Qualaquin
quinine sulfate
324mg
Appr
oved
AntiInfectives
Anti-PCP
Dapsone
dapsone
25, 100mg
Not
appro
ved
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
ADAP
Restricted to
David Powell
Clinic pharmacy
and prescribers
AntiInfectives
Anti-PCP
Mepron
atovaquone
750mg/5ml
Not
appro
ved
ADAP
AntiInfectives
Anti-PCP
Nebupent
pentamidine
300mg
Not
appro
ved
ADAP
AntiInfectives
Antiprotozoal
Flagyl (capsule)
metronidazole (capsule)
375mg
Appr
oved
AntiInfectives
Antiprotozoal
Flagyl (tablet)
metronidazole (tablet)
250, 500mg
Appr
oved
AntiInfectives
Antiprotozoal
Flagyl ER
(tablet)
metronidazole ER
(tablet)
750mg ER
Appr
oved
AntiInfectives
Antiretrovirals, CCR5
Antagonist
Selzentry
maraviroc
150, 300mg
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
ADAP
AntiInfectives
Antiretrovirals, Fusion
Inhibitors
Fuzeon
enfuvirtide
90mg/ml
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, Integrase
Inhibitor
Isentress
raltegravir
400mg
Appr
oved
Central
Pharma
cy
AntiInfectives
Antiretrovirals, Necleotide
RTI
Viread
tenofovir
300mg
Not
appro
ved
PAP
AntiInfectives
Antiretrovirals, NNRTI's
Intelence
etravirine
100mg
Not
appro
ved
ADAP
AntiInfectives
Rescriptor
delavirdine
100, 200mg
Not
appro
ved
ADAP
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
GI Clinic.
Overrides
approved if RX
written by GI (Dr.
Trevino/Dr.
Alam). Not
available outside
of
CommUnityCare
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
AntiInfectives
Sustiva
efavirenz
600mg
Appr
oved
Central
Pharma
cy
AntiInfectives
Viramune
nevirapine
50mg/ml; 200mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, NRTI's
Combivir
zidovudine/lamivudine
300/150mg
Not
appro
ved
ADAP
AntiInfectives
Emtriva
emtricitabine
10mg/ml; 200mg
Not
appro
ved
ADAP
AntiInfectives
Epivir
lamivudine
150, 300mg
Not
appro
ved
ADAP
AntiInfectives
Epzicom
lamivudine/abacavir
300/600mg
Not
appro
ved
ADAP
AntiInfectives
Retrovir
zidovudine
100, 300mg
Not
appro
ved
ADAP
AntiInfectives
Trizivir
zidovudine/lamivudine/
abacavir
300/150/300mg
Not
appro
ved
ADAP
AntiInfectives
Truvada
tenofovir/emtricitabine
300/200mg
Not
appro
ved
ADAP
AntiInfectives
Videx
didanosine
25, 50, 100, 125,
150, 200, 250, 375,
400mg
Not
appro
ved
ADAP
AntiInfectives
Zerit
stavudine
5, 15, 20, 30, 40mg
Not
appro
ved
ADAP
AntiInfectives
Ziagen
abacavir
20mg/ml; 300mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals,
NRTI's/NNRTI
Atripla
efavirenz/emtricitabine/
tenofovir
600/200/300mg
Not
appro
ADAP
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
ved
Clinic pharmacy
and prescribers
AntiInfectives
Antiretrovirals, PI
Aptivus
tipranavir
250mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, PI
Crixivan
indinavir
400mg
Appr
oved
Central
Pharma
cy
AntiInfectives
Antiretrovirals, PI
Invirase
saquinavir
200, 500mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, PI
Kaletra
lopinavir/ritonavir
80/20mg/ml; 100/25,
133.3/33.3,
200/50mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, PI
Lexiva
fosamprenavir
50mg/ml; 700mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, PI
Norvir
ritonavir
80mg/ml; 100mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, PI
Prezista
darunavir
300mg
Not
appro
ved
ADAP
AntiInfectives
Antiretrovirals, PI
Reyataz
atazanavir
200, 300mg
Appr
oved
Central
Pharma
cy
AntiInfectives
Antiretrovirals, PI
Viracept
nelfinavir
50mg/g; 250, 625mg
Not
appro
ved
ADAP
AntiInfectives
Anti-Viral
Relenza
zanamivir
5mg/inhalation
Appr
oved
AntiInfectives
Anti-Viral
Symmetrel
amantadine
Appr
oved
AntiInfectives
Anti-Viral
Valtrex
valacyclovir
50mg/5ml (473mL
syrup); 100mg
(tablet)
500, 1000mg
Retail
Networ
k
Retail
Networ
k
Retail
Networ
Appr
oved
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
David Powell
Clinic pharmacy
and prescribers
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
David Powell
Clinic pharmacy
and prescribers
AntiInfectives
Anti-Viral
Zovirax
acyclovir
200, 400, 800mg
(tablet)
Appr
oved
AntiInfectives
Anti-Viral
Zovirax
acyclovir
200mg/5ml (473mL
suspension)
Appr
oved
AntiInfectives
Anti-Viral Agents
Copegus
ribavirin
200mg
AntiInfectives
Anti-Viral Agents
Epivir HBV
lamivudine
100mg
AntiInfectives
Anti-Viral Agents
Hepsera
adefovir dipivoxil
10mg
AntiInfectives
Anti-Viral Agents
Rebetol
ribavirin
200mg
AntiInfectives
Anti-Viral Agents
Valcyte
valganciclovir
50mg/ml; 450mg
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
AntiInfectives
Anti-Virals
Tamiflu
oseltamivir
6mg/ml (60mL
suspension)
Appr
oved
AntiInfectives
Anti-Virals
Tamiflu
oseltamivir
30, 45, 75mg (tablet)
Appr
oved
AntiInfectives
Rifamycin
Xifaxan
rifaximin
200mg
AntiNeoplastic
s
AntiNeoplastic
s
AntiNeoplastic
s
Alkylating Agent
Alkeran tab
melphalan
2mg
Not
appro
ved
Appr
oved
Alkylating Agent
leukeran
chlorambucil
2mg
Appr
oved
Alkylating Agent
Lupron depo
leuprolide
3.75, 7.5, 11.25, 15,
22.5, 30mg
Not
appro
ved
AntiNeoplastic
s
AntiNeoplastic
s
AntiNeoplastic
s
Antimetabolite
Mercaptopurine
mercaptopurine
50mg
Appr
oved
Antimetabolite
Tabloid
thioguanine
40mg
Appr
oved
Aromatase Inhibitor
Arimidex
anastrozole
1mg
Appr
oved
k
Retail
Networ
k
Retail
Networ
k
PAP
PAP
PAP
PAP
ADAP
Restricted to
David Powell
Clinic pharmacy
and prescribers
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Pt to wait on
arrival from PAP.
No interim
prescriptions
available.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
AntiNeoplastic
s
AntiNeoplastic
s
AntiNeoplastic
s
AntiNeoplastic
s
Antirheum
atics
Estrogen Agonist/Antagonist
Nolvadex
tamoxifen
10, 20mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Myelosuppressant/ antiviral
Hydrea
hydroxyurea
500mg
Appr
oved
Progestins
Megace
(suspension)
megestrol (suspension)
40mg/ml
Appr
oved
Progestins
Megace (tablet)
megestrol (tablet)
40mg
Appr
oved
Immunosuppressants
Imuran
azathioprine
50mg
Appr
oved
Antirheum
atics
Immunosuppressants
Mexate
methotrexate
2.5mg
Appr
oved
Antirheum
atics
Miscellaneous agents
Enbrel Injection
etanercept
25mg
Not
appro
ved
Antirheum
atics
Monoclonal antibody
Humira
adalimumab
40mg/0.8ml
prefilled syringe
Not
appro
ved
PAP
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Anticoagulants
Coumadin,
Jantoven
warfarin
1, 2, 2.5, 3, 4, 5, 6,
7.5, 10mg
Appr
oved
Retail
Networ
k
Anticoagulants
Eliquis
apixaban
2.5, 5mg
Appr
oved
Central
Pharma
cy
Blood
Formation
&
Coagulati
on
Anticoagulants
Heparin
heparin
5000 units/ml
Appr
oved
Retail
Networ
k
Pt to wait on
arrival from PAP.
No interim
prescriptions
available.
Pt to wait on
arrival from PAP.
No interim
prescriptions
available.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Email *PAP for
override if needed
today. All other
prescribers,
warfarin is
preferred
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Anticoagulants
Heparin
heparin
10000 units/ml
Appr
oved
Retail
Networ
k
Anticoagulants
Lovenox
enoxaparin inj
Not
appro
ved
Nonformula
ry
CommUnityCare
prescribers email
*PAP for override.
All other
prescribers contact
MAP (512) 9788139
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Anticoagulants
Pradaxa
dabigatran
30mg/0.3mL,
40mg/0.4mL,
60mg/0.6mL,
80mg/0.8mL,
100mg/1mL,
120mg/0.8mL,
150mg/1mL,
300/3mg/ml
75, 150mg
Not
appro
ved
Nonformula
ry
Warfarin preferred
Anticoagulants
Xarelto
rivaroxaban
10, 15, 20mg
Not
appro
ved
Nonformula
ry
Warfarin preferred
Antiplatelet
Aggrenox
aspirin/dipyridamole
25/200mg
Not
appro
ved
PAP
Aspirin or
Clopidogrel
preferred
Antiplatelet
Brilinta
ticagrelor
90mg
Appr
oved
Central
Pharma
cy
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Antiplatelet
Effient
prasugrel
5, 10mg
Not
appro
ved
Nonformula
ry
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Clopidogrel
preferred
Antiplatelet
Plavix
clopidogrel
75mg
Appr
oved
Retail
Networ
k
Hematopoietics
Epogen
epoetin alfa
2000, 3000, 4000,
10000, 20000, 40000
units/ml
Not
appro
ved
PAP
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Blood
Formation
&
Coagulati
on
Cardiovas
cular
Hematopoietics
Neupogen
filgrastim
300mcg/ml,
300mcg/0.5ml,
480mcg/0.8ml,
480mcg/1.5ml
Not
appro
ved
PAP
Hematopoietics
Procrit
epotein alfa
2000, 3000, 4000,
10000, 20000, 40000
units/ml
Not
appro
ved
PAP
Hemorrheologics
Trental
pentoxifylline
400mg
Appr
oved
Retail
Networ
k
Platelet inhibition
Persantine
dipyridamole
50mg
Appr
oved
Retail
Networ
k
Platelet Inhibition
Pletal
cilostazol
50, 100mg
Appr
oved
Retail
Networ
k
Anti-Anginal
Imdur
isosorbide mononitrate
30, 60, 120mg
Appr
oved
Cardiovas
cular
Anti-Anginal
isosorbide dinitrate
2.5, 5, 10, 20, 30,
40mg
Appr
oved
Cardiovas
cular
Anti-Anginal
Isordil
(tablet/sublingual
tablet)
Nitroglycerin
nitroglycerin
2.5, 6.5, 9mg
Appr
oved
Cardiovas
cular
Anti-Anginal
Nitroglycerin
Patches
nitroglycerin patches
0.1, 0.2, 0.3, 0.4,
0.6mcg/hr
Appr
oved
Cardiovas
cular
Anti-Anginal
nitrolingual spray
sublingual nitroglycerin
0.4mg
Appr
oved
Cardiovas
cular
Anti-Anginal
Nitrostat/Quick
nitroglycerin S.L.
0.3, 0.4, 0.6mg
Appr
oved
Cardiovas
cular
Antiarrhythmic
Multaq
dronedarone
400mg
Cardiovas
cular
Antiarrhythmic- Class 1A
Norpace CR
disopyramide CR
100, 150mg
Not
appro
ved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Cardiovas
cular
Procan SR
procainamide SR
500mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Cardiovas
cular
Pronestyl
procainamide
250, 375, 500mg;
500mg SR
Appr
oved
Cardiovas
cular
Quinaglute
quinidine gluconate
324mg
Appr
oved
Cardiovas
cular
Antiarrhythmic- Class 1C
Rythmol
propafenone
150, 225, 300mg
Cardiovas
cular
Rythmol SR
propafenone
225, 325, 425mg
Cardiovas
cular
Tambocor
flecainide
50, 100, 150mg
Not
appro
ved
Not
appro
ved
Appr
oved
Cardiovas
cular
Antiarrhythmic- Class III
Cordarone,
Pacerone
amiodarone
200, 400mg
Appr
oved
Cardiovas
cular
Antiarrhythmic- Class IV
Digitek (elixir)
digoxin (elixir)
0.05mg/ml
Appr
oved
Cardiovas
cular
Antiarrhythmic- Class IV
Lanoxin, Digitek
(tablet)
digoxin (tablet)
0.125, 0.25mg
Appr
oved
Cardiovas
cular
AntihyperlipidemicAbsorption Inhibitors
Zetia
ezetimibe
10mg
Appr
oved
Cardiovas
cular
Antihyperlipidemic- Bile
Acid Sequestrants
Prevalite
cholestyramine light
4gm
Appr
oved
Cardiovas
cular
Acid Sequestrants
Questran
cholestyramine
4gm pkt & 4gm
pwdr
Appr
oved
Cardiovas
cular
Acid Sequestrants
Questran light
cholestyramine/asparta
me
4gm pkt & 4gm
pwdr
Appr
oved
Cardiovas
cular
Antihyperlipidemic- Fibric
Acid Derivatives
Lofibra capsule
fenofibrate micronized
67,134,200mg
Appr
oved
Cardiovas
cular
Acid Derivatives
Lofibra tablet
fenofibrate
54, 160mg
Appr
oved
Cardiovas
cular
Acid Derivatives
Lopid
gemfibrozil
600mg
Appr
oved
Cardiovas
cular
Acid Derivatives
Tricor
fenofibrate
48, 145mg
Cardiovas
Antihyperlipidemic-
Crestor
rosuvastatin
5, 10, 20, 40mg
Not
appro
ved
Appr
Retail
Networ
k
Retail
Networ
k
PAP
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
Central
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Lofibra is
preferred
Restricted to
cular
HMGCoA
oved
Pharma
cy
Cardiovas
cular
AntihyperlipidemicHMGCoA
Lipitor
atorvastatin
10, 20, 40, 80mg
Appr
oved
lovastatin
10, 20, 40mg
Appr
oved
Pravachol
pravastatin
10, 20, 40, 80mg
Appr
oved
Zocor
simvastatin
5, 10, 20, 40mg
Appr
oved
AntihyperlipidemicHMGCoA Combination
Products
AntihyperlipidemicHMGCoA Combination
Products
Advicor
lovastatin/niacin
20/500, 20/750,
20/1000, 40/1000mg
Vytorin
ezetimibe/simvastatin
10/10, 10/20, 10/40,
10/80mg
Not
appro
ved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Cardiovas
cular
Mevacor
Cardiovas
cular
Cardiovas
cular
Cardiovas
cular
Cardiovas
cular
Antihyperlipidemic- Nicotinic
Acids
Niaspan (Vitamin
B3)
niacin
500, 750, 1000mg
Appr
oved
Cardiovas
cular
Antihyperlipidemic- Omega3-Acid Ethyl Esters
Lovaza
omega-3-acid ethyl
esters
1g
Not
appro
ved
Cardiovas
cular
Antihypertensive- ACEI
Accupril
quinapril
5, 10, 20, 40mg
Appr
oved
Cardiovas
cular
Aceon
perindopril
2,4,8mg
Cardiovas
cular
Altace
ramipril
1.25, 2.5, 5, 10mg
Not
appro
ved
Appr
oved
Cardiovas
cular
Central
Pharma
cy
Retail
Networ
k
PAP
Retail
Networ
k
PAP
Retail
Networ
k
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
CommunityCare
prescribers
eligible for
override- Patient
must have
TG>500 for
override. Email
*PAP for override.
Other prescribers
must enroll in
PAP or use
fenofibrate.
Lisinopril
preferred
Cardiovas
cular
Capoten
captopril
12.5, 25, 50,100mg
Appr
oved
Cardiovas
cular
Lotensin
benazepril
5, 10, 20, 40mg
Appr
oved
Cardiovas
cular
Mavik
trandolapril
1, 2, 4mg
Appr
oved
Cardiovas
cular
Monopril
fosinopril
10, 20, 40mg
Appr
oved
Cardiovas
cular
Vasotec
enalapril
2.5, 5, 10, 20mg
Appr
oved
Cardiovas
cular
Zestril, Prinivil
lisinopril
2.5, 5, 10, 20, 30,
40mg
Appr
oved
Cardiovas
cular
AntihypertensiveACEI/Diuretic
Accuretic
quinapril/HCTZ
10/12.5, 20/12.5,
20/25mg
Appr
oved
Cardiovas
cular
Capozide
captopril/HCTZ
25/15, 25/25, 50/15,
50/25mg
Appr
oved
Cardiovas
cular
Lotensin HCT
benazepril/HCTZ
Appr
oved
Cardiovas
cular
Monopril HCT
fosinopril/HCTZ
5/6.25mg,
10/12.5mg,
20/12.5mg, 20/25mg
10/12.5, 20/12.5mg
Cardiovas
cular
Vaseretic
enalapril maleate/HCTZ
5/12.5, 10/25mg
Appr
oved
Cardiovas
cular
Zestoretic
lisinopril/HCTZ
10/12.5, 20/12.5,
20/25mg
Appr
oved
Cardiovas
cular
Antihypertensive- Alpha
agonist
Aldomet
methyldopa
250, 500mg
Appr
oved
Cardiovas
cular
agonist
Catapres
clonidine
0.1, 0.2, 0.3mg
Appr
oved
Cardiovas
cular
agonist
Catapres TTS
clonidine patch
TTS-1, TTS-2, TTS3
Appr
oved
Cardiovas
cular
agonist
Tenex
guanfacine
1mg, 2mg
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
Cardiovas
cular
blocker
Cardura
doxazosin
1, 2, 4, 8mg
Appr
oved
Retail
Networ
Appr
oved
Available to
CommUnityCare
prescribers only.
Email *PAP for
override. Not
available to other
prescribers.
Cardiovas
cular
blocker
Cardura XL
doxazosin extended
release
4, 8mg
Appr
oved
Cardiovas
cular
blocker
Hytrin
terazosin
1, 2, 5, 10mg
Appr
oved
Cardiovas
cular
blocker
Minipress
prazosin
1, 2, 5mg
Appr
oved
Cardiovas
cular
Antihypertensive- Alpha,
Beta Blocker
Coreg
carvedilol
3.125, 6.25, 12.5,
25mg
Appr
oved
Cardiovas
cular
Beta Blocker
Coreg-CR
carvedilol controlledrelease
10, 20, 40, 80mg
Not
appro
ved
Cardiovas
cular
Beta blocker
Normodyne,
Trandate
labetalol
100, 200, 300mg
Appr
oved
Cardiovas
cular
Antihypertensive- ARB
Avapro
irbesartan
75, 150, 300mg
Appr
oved
Cardiovas
cular
Benicar
Olmesartan
5, 20, 40mg
Cardiovas
cular
Cozaar
losartan
25, 50, 100mg
Not
appro
ved
Appr
oved
Cardiovas
cular
Diovan
valsartan
40, 80, 160, 320mg
Cardiovas
cular
Micardis
Telmisartan
20, 40, 80mg
Cardiovas
cular
Teveten
eprosartan
400, 600mg
Cardiovas
cular
/Diuretic
Avalide
irbesartan/HCTZ
150/12.5, 300/12.5,
300/25mg
Cardiovas
cular
/Diuretic
Diovan HCT
valsartan/HCTZ
160/25, 160/12.5,
80/12.5mg
Cardiovas
cular
/Diuretic
Hyzaar
losartan/HCTZ
50/12.5, 100/1.25,
100/25mg
Cardiovas
cular
Antihypertensive- Beta
Blocker
Betapace
sotalol
80, 120, 160, 240mg
Appr
oved
Cardiovas
cular
Blocker
Bystolic
nebivolol
5, 10mg
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
Appr
oved
Not
appro
ved
Appr
oved
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
Retail
Networ
k
PAP
Nonformula
ry
PAP
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
PAP
Carvedilol
ImmediateRelease is
preferred
Losartan,
Irbesartan are
preferred
Losartan,
Irbesartan are
preferred
Losartan,
Irbesartan are
preferred
Losartan,
Irbesartan are
preferred
Losartan/HCTZ or
Irbesartan/HCTZ
is preferred
Atenolol,
Metoprolol,
Carvedilol are
preferred
Cardiovas
cular
Blocker
Corgard
nadolol
20, 40, 80mg
Appr
oved
Cardiovas
cular
Blocker
Inderal
propanolol
10, 20, 40, 60, 80mg
Appr
oved
Cardiovas
cular
Blocker
Inderal LA
propranolol extended
release
60, 80, 120, 160mg
Appr
oved
Cardiovas
cular
Blocker /Diuretic
Ziac
bisoprolol/HCTZ
2.5/6.25, 5/6.25,
10/6.25mg
Appr
oved
Cardiovas
cular
Antihypertensive- Beta2
Blocker
Lopressor
metoprolol tartrate
25, 50, 100mg
Appr
oved
Cardiovas
cular
blocker
Tenormin
atenolol
25, 50, 100mg
Appr
oved
Cardiovas
cular
blocker /Diuretic
Tenoretic
atenolol/chlorthalidone
50/25, 100/25mg
Appr
oved
Cardiovas
cular
Antihypertensive- Calcium
Channel Blocker
Calan
verapamil IR
40, 80, 120mg
Appr
oved
Cardiovas
cular
Channel Blocker
Calan SR, Isoptin
SR
verapamil SR (12 hour
capsule)
120, 180, 240mg
Appr
oved
Cardiovas
cular
Channel Blocker
Cardizem
diltiazem IR
30, 60, 90, 120mg
Appr
oved
Cardiovas
cular
Channel Blocker
diltiazem ER - (24 hour
capsule)
120, 180, 240, 300,
360, 420mg
Appr
oved
Cardiovas
cular
Channel Blocker
Cardizem CD,
Cartia XT,
Dilacor ER, DiltCD, Diltzac,
Taztia XT,
Tiazac
Cardizem LA
diltiazem ER - (24
hours tablet)
120, 180, 240, 300,
360, 420mg
Appr
oved
Cardiovas
cular
Channel Blocker
Covera-HS
verapamil ER (24 hour
tablet)
180, 240mg
Appr
oved
Cardiovas
cular
Channel Blocker
Dynacirc CR
isradipine
5, 10mg
Cardiovas
cular
Channel Blocker
Norvasc
amlodipine
2.5, 5, 10mg
Not
appro
ved
Appr
oved
Cardiovas
cular
Channel Blocker
Procardia
nifedipine IR
10, 20mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Amlodipine
preferred
Cardiovas
cular
Channel Blocker
Procardia XL,
Adalat CC,
Nifedical XL (24
hour tablet)
nifedipine ER - (24
hour tablet)
30, 60, 90mg
Appr
oved
Central
Pharma
cy
Cardiovas
cular
Channel Blocker
Verelan
verapamil ER (24 hour
capsule)
120, 180, 240,
360mg
Appr
oved
Cardiovas
cular
Channel Blocker;
Antihyperlipidemic
Caduet
amlodipine/ atorvastatin
2.5/10. 2.5/20,
2.5/40mg; 5/10,
5/20, 5/40, 5/80mg;
10/10, 10/20, 10/40,
10/80mg
Appr
oved
Retail
Networ
k
Central
Pharma
cy
Cardiovas
cular
Antihypertensive- Carbonic
Anhydrase Inhibitors
Diamox
acetazolamide tablet
125, 250mg
Appr
oved
Cardiovas
cular
Antihypertensive- Carbonic
Anhydrase Inhibitors
Diamox Sequels
acetazolamide ER
capsule
500mg
Appr
oved
Cardiovas
cular
Antihypertensive
Combination
Lotrel
amlopidine/benzapril
2.5/10, 5/10, 5/20,
10/20mg
Appr
oved
Cardiovas
cular
Antihypertensive- direct renin
inhibitor
Tekturna
aliskiren
150, 300mg
Cardiovas
cular
Antihypertensive- diuretic,
Loop
Demadex
torsemide
5, 10, 20, 100mg
Not
appro
ved
Not
appro
ved
Cardiovas
cular
Loop
Lasix (solution)
furosemide
10mg/ml
Appr
oved
Cardiovas
cular
Loop
Lasix (tablet)
furosemide
20, 40, 80mg;
10mg/ml
Appr
oved
Cardiovas
cular
Potassium-sparing
Aldactone
spironolactone
25, 50, 100mg
Appr
oved
Cardiovas
cular
Potassium-sparing
Dyazide
triamterene/HCTZ
37.5/25, 50/25mg
Appr
oved
Cardiovas
cular
Potassium-sparing
Inspra
eplerenone
25, 50mg
Appr
oved
Cardiovas
Maxzide
triamterene/HCTZ
75/50mg
Appr
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Nonformula
ry
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Available to
CommUnityCare
prescribers only.
Email *PAP for
override. Not
available to other
prescribers.
cular
Potassium-sparing
oved
Cardiovas
cular
Potassium-sparing
Maxzide-25
triamterene/HCTZ
37.5/25mg
Appr
oved
Cardiovas
cular
Potassium-sparing
Midamor
amiloride
5mg
Appr
oved
Cardiovas
cular
Potassium-sparing
Moduretic
amiloride/HCTZ
5/50mg
Appr
oved
Cardiovas
cular
Thiazide
HydroDiuril,
Esidrix
hydrochlorothiazide
12.5, 25, 50mg
Appr
oved
Cardiovas
cular
Thiazide
Hygroton
chlorthalidone
25, 50mg
Appr
oved
Cardiovas
cular
Thiazide
Microzide
hydrochlorothiazide cap
12.5mg
Appr
oved
Cardiovas
cular
Thiazide-like
Lozol
indapamide
1.25, 2.5mg
Appr
oved
Cardiovas
cular
Thiazide-like
Zaroxolyn
metolazone
2.5, 5, 10mg
Appr
oved
Cardiovas
cular
Antihypertensive- Vasodilator
Apresoline
hydralazine
10, 25, 50, 100mg
Appr
oved
Cardiovas
cular
Loniten
minoxidil
2.5, 10mg
Appr
oved
Cardiovas
cular
Revatio
sildenafil
20mg
CNS
Agents
Acetylcholinesterase
Inhibitors
Aricept
donepezil
5, 10mg
Not
appro
ved
Appr
oved
CNS
Agents
Inhibitors
Exelon
rivastigmine
1.5, 3mg
Appr
oved
CNS
Agents
Inhibitors
Reminyl
galantamine
hydrobromide
4, 8, 12mg
Appr
oved
CNS
Agents
Alcohol Deterrents
Antabuse
disulfiram
250mg
Appr
oved
CNS
Agents
Alcohol Deterrents
Campral
acamprosate
333mg
CNS
Agents
Alcohol Deterrents
ReVia, Depade,
Trexan
naltrexone HCL
50mg
Not
appro
ved
Appr
oved
CNS
Anticonvulsants
Depakene
valproic acid (capsule)
250mg (capsule)
Appr
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Agents
(capsule)
oved
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
CNS
Agents
Anticonvulsants
Depakene (syrup)
valproic acid (syrup)
250mg/5ml (240mL)
Appr
oved
CNS
Agents
Anticonvulsants
Depakene (tablet)
valproic acid (tablet)
250mg (tablet)
Appr
oved
CNS
Agents
Anticonvulsants
Depakote (tablet)
divalproex sodium
enteric-coated (tablet)
125, 250, 500mg
(tablet)
Appr
oved
CNS
Agents
Anticonvulsants
Depakote ER
(tablet)
250, 500mg (tablet)
Appr
oved
CNS
Agents
Anticonvulsants
125mg sprinkle
capsules
Appr
oved
CNS
Agents
Anticonvulsants
Depakote
Sprinkle
Capsules
Dilantin
(suspension)
divalproex sodium
extended-release
(tablet)
divalproex sodium
enteric-coated sprinkle
(capsules)
phenytoin (suspension)
125mg/5ml susp
Appr
oved
CNS
Agents
Anticonvulsants
Dilantin Infatabs
phenytoin
50mg chewable
tablet
Appr
oved
CNS
Agents
Anticonvulsants
Dilantin Kapseal
phenytoin extendedrelease
100mg
Appr
oved
Central
Pharma
cy
CNS
Agents
Anticonvulsants
Keppra (solution)
levetiracetam (solution)
100mg/ml (solution)
Appr
oved
CNS
Agents
Anticonvulsants
Keppra (tablet)
levetiracetam (tablet)
250, 500, 750,
1000mg (tablet)
Appr
oved
CNS
Agents
Anticonvulsants
Keppra XR
levetiracetam extendedrelease
500, 750mg
CNS
Agents
Anticonvulsants
Lamictal
lamotrigine
25, 100, 150, 200mg
Not
appro
ved
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
PAP
CNS
Agents
Anticonvulsants
Mysoline
primidone
50, 250mg
Appr
oved
PAP
Retail
Networ
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Keppra
ImmediateRelease preferred
CommUnityCare
prescribers email
*PAP for override
approval today.
Other prescribers
must enroll in
PAP.
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
CNS
Agents
Anticonvulsants
Neurontin
gabapentin
100, 300, 400, 600,
800mg
Appr
oved
CNS
Agents
Anticonvulsants
Neurontin
gabapentin oral solution
250mg/5ml
Appr
oved
CNS
Agents
Anticonvulsants
Phenobarbital
(tablet/elixir)
phenobarbital
Appr
oved
CNS
Agents
Anticonvulsants
Phenytek
phenytoin extendedrelease
15, 30, 60, 100, 32.4,
64.8, 97.2mg;
20mg/5ml elixir
100mg, 200mg,
300mg
CNS
Agents
Anticonvulsants
Tegreol XR
carbamazepine
100, 200, 400mg
(tablet)
Appr
oved
CNS
Agents
Anticonvulsants
Tegretol
(suspension)
carbamazepine
100mg/5ml
(suspension)
Appr
oved
CNS
Agents
Anticonvulsants
Tegretol (tablet)
carbamazepine
100, 200mg (tablet)
Appr
oved
CNS
Agents
Anticonvulsants
Topamax
(sprinkle capsule)
topiramate
15, 25mg sprinkle
capsules
Not
appro
ved
CNS
Agents
Anticonvulsants
Topamax (tablet)
topiramate
25, 50, 100, 200mg
Not
appro
ved
PAP
CNS
Agents
Anticonvulsants
Trileptal
(suspension)
oxcarbazepine
(suspension)
300mg/5 mL (
250ml)
Appr
oved
CNS
Agents
Anticonvulsants
Trileptal (tablet)
oxcarbazepine (tablet)
150, 300, 600mg
Appr
oved
CNS
Agents
Anticonvulsants
Vimpat
lacosamide
50, 100, 150, 200mg
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
PAP
CNS
Agents
Anticonvulsants
Zonegran
zonisamide
25, 50, 100mg
Appr
oved
Appr
oved
Retail
Networ
k
CommUnityCare
prescribers email
*PAP for override
approval today.
Other prescribers
must enroll in
PAP.
CommUnityCare
prescribers email
*PAP for override
approval today.
Other prescribers
must enroll in
PAP.
CommUnityCare
prescribers email
*PAP for override
approval today.
Other prescribers
must enroll in
PAP.
CNS
agents
Anticonvulsants,
miscellaneous
Lyrica
pregabalin
25, 50, 75, 100, 150,
200, 225, 300mg
Appr
oved
Central
Pharma
cy
CNS
Agents
Antidepressant
Desyrel
trazodone
50, 100,150, 300mg
Appr
oved
CNS
Agents
Antidepressant
Viibryd
vilazodone
20, 40, 80mg
CNS
Agents
Antidepressant
Wellbutrin
bupropion
75, 100mg
Not
appro
ved
Appr
oved
CNS
Agents
Antidepressant
Wellbutrin SR
bupropion (SR)
100, 150, 200mg
Appr
oved
CNS
Agents
Antidepressant
Wellbutrin XL
bupropion (XL)
150, 300mg
Appr
oved
CNS
Agents
Antidepressant-SNRI
Cymbalta
duloxetine
20, 30, 60mg
CNS
Agents
Antidepressant-SNRI
Effexor
venlafaxine
25, 37.5, 50, 100mg
Not
appro
ved
Appr
oved
Retail
Networ
k
Nonformula
ry
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
CNS
Agents
Antidepressant-SNRI
Effexor XR
venlafaxine extendedrelease
37.5, 75, 150mg
Appr
oved
CNS
Agents
Antidepressant-SNRI
Pristiq
desvenlafaxine
50, 100mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Celexa
citalopram
10, 20, 40mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Lexapro
(solution)
escitalopram
5mg/5ml (240ml)
Appr
oved
CNS
Agents
Antidepressant-SSRI
Lexapro (tablet)
escitalopram
5, 10, 20mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Luvox
fluvoxamine maleate
50, 100mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Paxil
(suspension)
paroxetine
10mg/5ml
Appr
oved
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Escitalopram
preferred
Effexor XR
preferred
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Limit 40mg per
day
Limit 20mg per
day
Limit 20mg per
day
CNS
Agents
Antidepressant-SSRI
Paxil (tablet)
paroxetine
10, 20, 30, 40mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Paxil CR
paroxetine HCL
12.5, 25, 37.5mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Prozac
fluoxetine
10, 20, 40mg
Appr
oved
CNS
Agents
Antidepressant-SSRI
Zoloft
sertraline
25, 50, 100mg
Appr
oved
CNS
Agents
Antidepressant-Tetracyclic
Remeron
mirtazapine
15, 30, 45mg
Appr
oved
CNS
Agents
Antidepressant-Tricyclic
Elavil
amitriptyline
10, 25, 50, 75, 100,
150mg
Appr
oved
CNS
Agents
Pamelor
nortriptyline
10, 25, 50, 75mg
Appr
oved
CNS
Agents
Sinequan
doxepin
10, 25, 50, 75,
100mg
Appr
oved
CNS
Agents
Tofranil
imipramine
10, 25, 50mg
Appr
oved
CNS
Agents
Anti-Diarrheal Agents
Lomox
diphenoxylate/atropine
2.5/0.025mg
Appr
oved
CNS
Agents
Antimanic agents
Eskalith
lithium carbonate
300mg; 300, 450mg
ER
Appr
oved
CNS
Agents
Antimanic agents
Lithobid
lithium carbonate
extended-release
300, 450mg ER
Appr
oved
CNS
Agents
Antimigraine agents
Axert
almotriptan
6.25,12.5mg
CNS
Agents
Antimigraine agents
Fioricet; Esgic
acetaminophen/butalbit
al/caffeine
325/50/40mg
Not
appro
ved
Appr
oved
CNS
Agents
Antimigraine agents
Fiorinal
ASA/caffeine/butalbital
325/50/40mg
Appr
oved
CNS
Agents
Antimigraine agents
Imitrex Nasal
Spray
sumatriptan nasal spray
5mg and 20mg
Appr
oved
CNS
Agents
Antimigraine agents
Imitrex Statdose
sumatriptan injection
6mg/0.5ml syringe
Appr
oved
CNS
Agents
Antimigraine agents
Imitrex tablet
sumatriptan tablet
25, 50, 100mg tablet
Appr
oved
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
Imitrex is
preferred
Limit 2 boxes or
12 containers per
month
Limit 2 boxes or 4
cartridges per
month
Limit 9 tablets per
month
k
Central
Pharma
cy
CNS
Agents
Antimigraine agents
Maxalt
rizatriptan
5, 10mg tablet
Appr
oved
CNS
Agents
Antimigraine agents
Maxalt MLT
rizatriptan ODT
5, 10mg ODT
Appr
oved
Central
Pharma
cy
CNS
Agents
Antimigraine agents
Midrin
65/100/325mg
Appr
oved
CNS
Agents
Antimigraine agents
Migratine
65/100/325mg
Appr
oved
CNS
Agents
Antimigraine agents
Relpax
isometheptene/dichloral
phenazone/acetaminoph
en
isometheptene/dichloral
phenazone/acetaminoph
en
eletriptan
20, 40mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
CNS
Agents
Antimigraine agents
Treximet
sumatriptan/naproxen
85/500mg
CNS
Agents
Antimigraine agents
Zomig (nasal
spray)
zolmitriptan
5mg nasal
CNS
Agents
Antimigraine agents
Zomig (tablet)
zolmitriptan
2.5, 5mg; 5mg nasal
CNS
Agents
Anti-Parkinsons,
Anticholinergic
Artane
trihexyphenidyl
2, 5mg
Not
appro
ved
Not
appro
ved
Not
appro
ved
Appr
oved
CNS
Agents
Anti-Parkinsons,
Anticholinergic
Cogentin
benztropine
0.5, 1, 2mg
Appr
oved
CNS
Agents
Anti-Parkinsons, COMT
inhibitor
Comtan
entacapone
200mg
Appr
oved
CNS
Agents
Anti-Parkinsons, Dopamin
Agonist
Parlodel
(tablet/capsule)
bromocriptine mesylate
2.5, 5mg
Appr
oved
CNS
Agents
Anti-Parkinsons, Dopamine
Agonist
Mirapex
pramipexole
0.125, 0.25, 0.5, 1,
1.5mg
Appr
oved
PAP
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Imitrex is
preferred
PAP
Imitrex is
preferred
PAP
Imitrex is
preferred
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
CNS
Agents
Agonist
Requip
ropinirole
0.25, 0.5, 1, 2, 4mg
Appr
oved
CNS
Agents
Agonist
Symmetrel
amantadine
100mg
Appr
oved
CNS
Agents
Precursor
Sinemet
carbidopa/levodopa
immediate-release
10/100, 25/100,
25/250mg
Appr
oved
CNS
Agents
Precursor
Sinemet CR
carbidopa/levodopa
controlled release
25/100, 50/200mg
Appr
oved
CNS
Agents
Antipsychotics, atypical
Abilify
aripiprazole
2, 5, 10, 15, 20,
30mg tablet
Appr
oved
CNS
Agents
Fanapt
iloperidone
1, 2, 4, 6, 8, 10 ,
12mg
Not
appro
ved
PAP
CNS
Agents
Geodon
ziprasidone
40, 80mg
Not
appro
ved
Nonformula
ry
CNS
Agents
Invega
paliperidone
3, 6, 9mg
PAP
CNS
Agents
Latuda
lurasidone
40, 80mg
Not
appro
ved
Not
appro
ved
CNS
Agents
Risperdal
(tablets)
risperidone
0.25, 0.5, 1, 2, 3 mg
Appr
oved
CNS
Agents
Saphris
asenapine sublingual
tablet
5, 10mg
CNS
Agents
Seroquel
quetiapine
25, 50, 100, 200,
300, 400mg
Not
appro
ved
Appr
oved
Retail
Networ
k
PAP
CNS
Agents
Seroquel XR
quetiapine extended
release
50, 150, 200, 300,
400mg
Appr
oved
PAP
Retail
Networ
k
Central
Pharma
cy
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Patient will need
to wait for PAP.
No interim
prescriptions are
available.
Restricted to
CommUnityCare
prescribers. Email
*PAP to request
override. Not
available to other
prescribers
Risperidone is
preferred.
Patient will need
to wait for PAP.
No interim
prescriptions are
available.
Limit to 2
tablets/day.
Limit to 2
tablets/day.
Restricted to
CommUnityCare
prescribers, Send
RX to
CNS
Agents
Zyprexa
olanzapine
2.5, 5, 7.5, 10, 15,
20mg
Not
appro
ved
PAP
CNS
Agents
Zyprexa Zydis
ODT
olanzapine orally
disintegrating tablet
5mg
Not
appro
ved
PAP
CNS
Agents
Antipsychotics, atypical/SSRI
combo
Symbyax
olanzapine/fluoxetine
6/25, 6/50mg
Not
appro
ved
PAP
CNS
Agents
Antipsychotics, Typical
Haldol
haloperidol
0.5, 1, 2, 5, 10,
20mg; 50, 100mg/ml
Appr
oved
CNS
Agents
Loxitane
loxapine succinate
5, 10, 25, 50mg
Appr
oved
CNS
Agents
Navane
thiothixene
1, 2, 5, 10mg
Appr
oved
CNS
Agents
Prolixin
(solution)
fluphenazine
5mg/ml
Appr
oved
CNS
Agents
Prolixin (tablet)
fluphenazine
1, 2.5, 5, 10mg
Appr
oved
CNS
Agents
Serentil
mesoridazine besylate
100mg
Appr
oved
CNS
Agents
Trilafon
perphenazine
2, 4, 8, 16mg
Appr
oved
CNS
Agents
Benzodiazepines
Ativan
lorazepam
0.5, 1, 2mg
Appr
oved
CNS
Agents
Benzodiazepines
Buspar
buspirone
5, 7.5, 10, 15, 30mg
Appr
oved
CNS
Agents
Benzodiazepines
Dalmane
flurazepam
15, 30mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
CommUnityCare
prescribers email
*PAP for override
approval today.
Other prescribers
must enroll in
PAP.
CommUnityCare
prescribers email
*PAP for override
approval today.
Other prescribers
must enroll in
PAP.
CommUnityCare
prescribers email
*PAP for override
approval. Other
prescribers must
enroll in PAP.
CNS
Agents
Benzodiazepines
Klonopin
clonazepam
0.5, 1, 2mg
Appr
oved
CNS
Agents
Benzodiazepines
Librium
chlordiazepoxide
25mg
Appr
oved
CNS
Agents
Benzodiazepines
Restoril
temazepam
7.5, 15, 30mg
Appr
oved
CNS
Agents
Benzodiazepines
Serax
oxazepam
10, 15, 30mg
Appr
oved
CNS
Agents
Benzodiazepines
Tranxene
clorazepate
3.75, 7.5, 15mg
Appr
oved
CNS
Agents
Benzodiazepines
Valium
diazepam
2, 5, 10mg
Appr
oved
CNS
Agents
Benzodiazepines
Xanax
alprazolam
0.25, 0.5, 1, 2mg
Appr
oved
CNS
Agents
Cholinergic
Evoxac
cevimeline capsule
30mg
CNS
Agents
Cholinesterase Inhibitor
Mestinon
Timespan
pyridostigmine
180mg
CNS
Agents
Hyperprolactemia
Dostinex
cabergoline
0.5mg
Not
appro
ved
Not
appro
ved
Appr
oved
CNS
Agents
Namenda
memantine
5, 10mg
CNS
Agents
Narcolepsy
Dextroamphetam
ine
d-amphetamine sulfate
5mg
CNS
Agents
Parkinson's
Stalevo
carbidopa/levodopa/ent
acapone
50, 100mg
CNS
Agents
Sedative-Hypnotic
Ambien
zolpidem
5, 10mg
CNS
Agents
Sedative-Hypnotic
Sonata
zaleplon
5, 10mg
CNS
Agents
Sedative-Hypnotic/Melatonin
Receptor Agonist
Rozerem
ramelteon
8mg
CNS
Agents
Skeletal Muscle Relaxants
Flexeril
cyclobenzaprine
5, 10mg
CNS
Agents
Lioresal
baclofen
10, 20mg
Not
appro
ved
Appr
oved
Not
appro
ved
Appr
oved
Not
appro
ved
Not
appro
ved
Appr
oved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
PAP
Retail
Networ
k
PAP
Retail
Networ
k
PAP
Limit 6 tablets/day
Retail
Networ
k
PAP
Limit 10mg per
day
PAP
Melatonin
preferred
Retail
Networ
k
Retail
Networ
k
Zolpidem
preferred
CNS
Agents
Paraflex
chlorzoxazone
250mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
CNS
Agents
Parafon Forte
chlorzoxazone DS
500mg
Appr
oved
CNS
Agents
Robaxin
methocarbamol
500, 750mg
Appr
oved
CNS
Agents
Skelaxin
metaxolone
400, 800mg
Appr
oved
CNS
Agents
Soma
carisoprodol
350mg
Appr
oved
CNS
Agents
Zanaflex
tizanidine
2, 4mg
Appr
oved
CNS
Agents
Smoking Cessation
Chantix
varenicline
Starter box (0.5mg,
1mg)
Appr
oved
CNS
Agents
Smoking Cessation
Chantix
varenicline
Continuing month
box (1mg)
Appr
oved
Central
Pharma
cy
CNS
Agents
Smoking Cessation
Nicotrol Inhaler
nicotine
10mg inhaler
Appr
oved
Central
Pharma
cy
CNS
Agents
Stimulants
Adderall
dextroamphetamine/am
phetamine salts
5, 7.5, 10, 12.5, 15,
20, 30mg
Appr
oved
CNS
Agents
Stimulants
Adderall XR
5, 10, 15, 20, 25,
30mg XR
Appr
oved
CNS
Agents
Stimulants
Concerta
dextroamphetamine/am
phetamine extended
release salts
methylphenidate OROS
18, 36mg
CNS
Agents
Stimulants
Focalin
dexmethylphenidate
2.5, 5, 10mg
Not
appro
ved
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
PAP
PAP
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Limit to 2
tablets/day
Limit to 2
tablets/day
Metadate CD is
preferred
Ritalin is preferred
CNS
Agents
Stimulants
Focalin XR
dexmethylphenidate SR
5, 10, 20mg
Not
appro
ved
Appr
oved
CNS
Agents
Stimulants
Metadate CD
10, 20, 30, 40, 50,
60mg
CNS
Agents
Stimulants
Methylin ER
methylphenidate
extended-release
capsule
methylphenidate
extended-release
10, 20mg
Appr
oved
CNS
Agents
Stimulants
Nuvigil
armodafinil
150mg
CNS
Agents
Stimulants
Provigil
modafinil
100, 200mg
CNS
Agents
Stimulants
Ritalin
methylphenidate
5, 10, 20mg
Not
appro
ved
Not
appro
ved
Appr
oved
CNS
Agents
Stimulants
Strattera
atomoxetine
10, 25, 40, 80,
100mg
CNS
Agents
Stimulants
Vyvanse
lisdexamfetamine
20, 50, 70mg
Dermatolo
gical
Acne/Rosacea
Azelex cream
azelaic acid 20%
30, 50g
Dermatolo
gical
Acne/Rosacea
benzoyl peroxide
5% gel
benzoyl peroxide 5%
gel
42.5, 90g
Appr
oved
Dermatolo
gical
Acne/Rosacea
Claravis
isotretinoin
10, 20, 30, 40mg
Appr
oved
Dermatolo
gical
Acne/Rosacea
Cleocin-T
clindamycin 1%
gel/lotion/solution
30, 60ml
Appr
oved
Dermatolo
gical
Acne/Rosacea
Differin gel
adapalene
0.3% 45g
Dermatolo
gical
Acne/Rosacea
MetroGel
Topical
metronidazole topical
gel
0.75%, 1%, 1% w/
cleanser kit
Not
appro
ved
Appr
oved
Dermatolo
gical
Acne/Rosacea
Retin-A
(Cream/Gel)
tretinoin
0.01%, 0.025%,
0.05%, 0.1% 45g
Appr
oved
Dermatolo
gical
Acne/Rosacea
Retin-A Micro
tretinoin microsphere
gel
0.04, 0.1%
Appr
oved
Dermatolo
gical
Acne/Rosacea
Tazorac
(cream/gel)
tazarotene
0.05%, 0.1% - 15,
30, 60g
Not
appro
ved
Not
appro
ved
Not
appro
ved
Appr
oved
PAP
Metadate CD is
preferred
Retail
Networ
k
Retail
Networ
k
PAP
Limit 2 tablets/day
Limit 5 tablets/day
PAP
Retail
Networ
k
PAP
Limit 3 tablets/day
PAP
Adderral XR is
preferred
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Resctricted to
CommUnityCare
Derm Clinic (Dr.
Ahmed).
Dermatolo
gical
Anti-Fungal Agents, Topical
Mycolog II
nystatin/triamcinolone
cream/oint
100,000U/0.1%/g
30g
Appr
oved
Dermatolo
gical
nystatin
100,000U/g 30g
Appr
oved
Dermatolo
gical
Mycostatin
(ointment/cream/
powder)
Nizoral
shampoo/cream
ketoconazole
2% cream, 2%
shampoo
Appr
oved
Dermatolo
gical
Penlac
ciclopirox
Appr
oved
Dermatolo
gical
Anti-Fungal/antiinflammatory, Topical
Lotrisone
clotrimazole/betamethas
one
0.77% cream/gel;
1% shampoo; 8%
solution
1-.05%
Dermatolo
gical
Anti-Fungal/antiinflammatory, Topical
Mycogen II
cream
nystatin/triamcinolone
cream
100mu-.1%/gm
Appr
oved
Dermatolo
gical
Anti-Infective Agents
Aldara
imiquimod
5% cream pack
Appr
oved
Dermatolo
gical
ATS 2% topical
solution
erythromycin topical
solution
2% 60ml
Appr
oved
Dermatolo
gical
Bactroban
ointment
mupirocin ointment
2% 15g
Appr
oved
Dermatolo
gical
Anti-infective Agents
Erythromycin
Topical
erythromycin topical
solution
2% 60ml
Appr
oved
Dermatolo
gical
Metrogel
metronidazole
0.75%, 1% cream,
gel, lotion
Appr
oved
Dermatolo
gical
Silvadene
silver sulfadiazine
cream
1% 85g
Appr
oved
Dermatolo
gical
triple antibiotic
ointment (drops)
neomycin/bacitracin/pol
ymyxin
Dermatolo
gical
Antipsoriatic
Dovonex
calcipotriene
Dermatolo
gical
Antipsoriatic
Protopic 0.1%
ointment
tacrolimus topical
ointment
Dermatolo
gical
Antipsoriatic
Soriatane
acitretin
10, 25mg
Dermatolo
gical
Antiviral
Zovirax
acyclovir 5%
cream/ointment
2g (cream); 4, 15,
30g (ointment)
Dermatolo
gical
Corticosteroid, Topical
Derma-Smoothe
scalp oil
fluocinolone 0.01%
0.01%/4oz
Appr
oved
Appr
oved
0.005%
cream,ointment,scal
p soln.
0.1%; 30, 60, 100g
Appr
oved
Not
appro
ved
Not
appro
ved
Appr
oved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
PAP
Retail
Networ
k
Retail
Networ
k
Dermatolo
gical
Desowen
desonide
cream/ointment
0.05%
Appr
oved
Dermatolo
gical
Diprolene
betamethasone
0.05% lotion, 30 ml
Appr
oved
Dermatolo
gical
Diprolene AF
betamethasone
0.05% cream
Appr
oved
Dermatolo
gical
betamethasone
dipropionate
0.05%
Appr
oved
Dermatolo
gical
hydrocortisone
2% cream/oint/lotion
Appr
oved
Dermatolo
gical
hydrocortisone cream
2.5% 30g
Appr
oved
Dermatolo
gical
triamcinolone acetonide
0.025%, 0.1%, 0.5%
15g
Appr
oved
Dermatolo
gical
Diprolene
ointment,cream,g
el,lotion
Hydrocortisone(c
ream,lotion,oint
ment)
Hytone
(cream/lotion/oin
tment)
Kenalog
(ointment/cream/
lotion)
Lidex
fluocinonide
Appr
oved
Dermatolo
gical
Temovate(cream,
oint,solution)
clobetasol
0.05%
ointment,gel,cream,s
olution
0.05% 15, 30, 45,
60gm
Dermatolo
gical
betamethasone valerate
0.1% 15g, 45g /
0.1% 60ml
Appr
oved
Dermatolo
gical
Emollient
Valisone
(cream/lotion/oin
tment)
Carmol 40
urea 40% topical cream
40%/30g
Appr
oved
Dermatolo
gical
Immunosuppressant
Efudex
fluorouracil 5% cream;
2% & 5% solution
40g (cr); 10, 25ml
(sol)
Appr
oved
Dermatolo
gical
Immunosuppressant
Elidel
pimecrolimus
1% cream
Appr
oved
Dermatolo
gical
Keratolytic
Condylox
podofilox
0.5% gel 3.5g
Appr
oved
Dermatolo
gical
Miscellaneous
Biafine Topical
Emulsion
45, 90g
Dermatolo
gical
Scabicide/ Pediculocide
Elimite/ Acticin
permethrin cream
5% 60g
Not
appro
ved
Appr
oved
Dermatolo
gical
Lindane (lotion)
lindane (lotion)
1% 60ml
Appr
oved
Dermatolo
gical
Lindane
(shampoo)
lindane (shampoo)
1% 60ml
Appr
oved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Dermatolo
gical
Permethrin
permethrin
1% lotion
Appr
oved
EENT
Anticholinergic, Nasal
Atrovent Nasal
Spray
ipratropium nasal spray
0.03%/30ml,
0.06%/15ml
EENT
Corticosteroids, Nasal
Beconase AQ
beclomethasone
dipropionate
42mcg/inhalation
25g
Not
appro
ved
Appr
oved
EENT
Flonase
fluticasone
50mcg/actuation
16g-.5%
Appr
oved
EENT
Nasacort;
Nasacort AQ
triamcinolone
55mcg/actuation
Appr
oved
EENT
Nasarel
flunisolide
25mcg/actuation
25ml
Appr
oved
EENT
Nasonex
mometasone
50mcg/actuation
Appr
oved
EENT
Veramyst
fluticasone
27mcg/actuation
EENT
Glaucoma Agents
Alphagan
brimonidine tartrate
0.2% drops
Not
appro
ved
Appr
oved
EENT
Glaucoma Agents
Alphagan-P
brimonidine
0.15%/ml-5, 10, 15
Appr
oved
EENT
Glaucoma Agents
Azopt
brinzolamide
1% 10ml
Appr
oved
EENT
Glaucoma Agents
Betagan
levobunolol ophth
solution
0.5% 5ml,
10ml,0.25%
Appr
oved
EENT
Glaucoma Agents
Combigan
brimonidine
tartrate/timolol maleate
0.2%-0.5%
EENT
Glaucoma Agents
Cosopt Ocumeter
dorzolamide
HCl/timolol maleate
5ml, 10ml
Not
appro
ved
Appr
oved
EENT
Glaucoma Agents
Lumigan
bimatropost
0.01% drops
Appr
oved
EENT
Glaucoma Agents
Pilocar
pilocarpine ophth
solution
0.5%,1%, 2%, 3%,
4%, 6% 15ml
Appr
oved
EENT
Glaucoma Agents
Salagen
pilocarpine HCL(tab)
5, 7.5mg
Appr
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
PAP
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Flonase is
preferred
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Restricted to
opthamology
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
oved
EENT
Glaucoma Agents
Timoptic,
Timoptic XE
timolol ophth solution,
gel
0.25%, 0.5% 5ml,
10ml
Appr
oved
EENT
Glaucoma Agents
Travatan
travoprost
0.004% drops
Appr
oved
EENT
Glaucoma Agents
Trusopt
dorzolamide ophth
solution
2% - 5, 10mL
Appr
oved
EENT
Glaucoma Agents
Xalatan
ophthalmic
latanoprost
0.005%
Appr
oved
EENT
Ophthalmic Anti-infectives
Bacitracin
bacitracin ophth
ointment
3.5g
Appr
oved
EENT
Ciloxan
ciprofloxacin ophth
drops, ointment
0.3% 2.5ml, 5ml,
3.5g ung
Appr
oved
EENT
Garamycin/Geno
ptic
(ointment/solutio
n)
gentamicin ophth
Appr
oved
EENT
Ilotycin
erythromycin ophth
ointment
0.3% 3.5g / 0.3%
5ml,
15ml,.1%cream,.1%
ointment,3mg/ml/3m
g/gm
3.5g
EENT
Neosporin
ophthalmic oint.
neomycin/bacitracin/pol
ymyxin ophth
3.5 gm
Appr
oved
EENT
neomy/polymyx/gramic
idin ophth
10ml
Appr
oved
EENT
sulfacetamide ophth
10% 3.75g / 10%
15ml
Appr
oved
EENT
Neosporin
opthalmic
solution
Sulfacetamide
Ophth
(ointment/solutio
n)
Tobrex
tobramycin ophth
solution
0.3% 5ml
Appr
oved
EENT
Vigamox
ophthalmic
moxifloxacin ophth
solution
0.5%
Appr
oved
EENT
Viroptic
ophthammic
trifluridine ophth
solution
1%
Appr
oved
EENT
Ophthalmic Anti-infectives /
Anti-Inflammatory
neomycin/polymyxin/de
xamethasone ophth
3.5g / 5ml
Appr
oved
EENT
Ophthalmic Anti-infectives /
Anti-Inflammatory
Maxitrol
(ointment/suspen
sion)
Tobradex
(drops/ointment)
tobramycin/dexamethas
one
0.3 /0.1%
Appr
oved
EENT
Ophthalmic Anti-
Acular
ketorolac ophth drops
3, 5, 10ml
Appr
Appr
oved
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
Inflammatory
0.5%
oved
EENT
Ophthalmic AntiInflammatory
Lotemax
loteprednol etobonate
0.5% drops
Appr
oved
EENT
Ocufen
flurbiprofen ophth
solution
0.03% 2.5ml
Appr
oved
EENT
Opticrom
cromolyn 4% drops
10ml
Appr
oved
EENT
Pred-Forte
prednisolone acetate
ophth suspension
1%
Appr
oved
EENT
prednisolone sodium
phosphate
1% drop
Appr
oved
EENT
prednisolone
sodium
phosphate
Restasis
cyclosporine
0.05% solution
EENT
Voltaren
diclofenac ophthalmic
solution
0.1%
Not
appro
ved
Appr
oved
EENT
Opthalmic Antihistamine
Patanol
olopatadine
0.1% drops 5ml
Appr
oved
EENT
Otic Anti-infectives
A/B otic drops
antipyrine/benzocaine
otic solution
10ml
Appr
oved
EENT
Acetasol HC
2-1%
Appr
oved
EENT
Acetic Acid Otic
Solution
acetic
acid/hydrocortisone otic
solution
acetasol 2% ear solution
2% 15ml
Appr
oved
EENT
Antibiotic Ear
solution
neomycin/polymyxin/hc
1% solution
Appr
oved
EENT
Antibiotic Ear
suspension
neomycin/polymyxin/hc
1% suspension
Appr
oved
EENT
Auralgan
antipyrine/benzocaine
otic solution
10ml
Appr
oved
EENT
Cipro HC otic
suspension
ciprofloxacin /
hydrocortisone
.2-1%,5%
Appr
oved
EENT
Ciprodex
ciprofloxacin /
dexamethasone otic
10ml
Appr
oved
EENT
Cortisporin Otic
neomy/polymyx/hydroc
ort otic solu
10ml
Appr
oved
EENT
Floxin
ofloxacin otic solution
0.3% solution
Appr
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
opthamology
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
Restricted to
opthamology
oved
EENT
Vosol HC
acetic acid/hydrocort
otic solution
2%/1% 10ml
Appr
oved
Electrolyti
c, Caloric
Calcium Salts
PhosLo
(gelcap,tablet)
calcium acetate
667mg
Appr
oved
Electrolyti
c, Caloric
Exchange Resin
Kayexalate
sodium polystyrene
sulfonate
60, 240ml
Appr
oved
Electrolyti
c, Caloric
Phosphate-removing Agents
Renagel
sevelamer HCL
400, 403 ,800mg
Appr
oved
Electrolyti
c, Caloric
Potassium Supplement
K-Dur, K-ciel,
K-lor, etc
potassium chloride
Appr
oved
Electrolyti
c, Caloric
Potassium Supplement
Urocit-K
potassium citrate
10, 20, 30, 40meq
powder/tablet/liquid
formulations
5, 10meq
Electrolyti
c, Caloric
Uricosuric
Probenecid
probenecid
500mg
Appr
oved
Gastrointe
stinal
Ammonia Detoxicant/
Laxative
Cephulac
lactulose
10g/15ml 480ml,
960ml,20gm/30ml
Appr
oved
Gastrointe
stinal
Ammonia Detoxicants
Constulose
lactulose
10g/15ml
480ml,20mg/30ml
Appr
oved
Gastrointe
stinal
Anti-Emetic Agents
prochlorperazine
5mg,10mg, 2.5, 5,
25
Appr
oved
Gastrointe
stinal
Anti-Emetic Agents
promethazine
Anti-Emetic Agents
12.5mg, 25mg,
50mg tab; 6.25/5ml;
12.5, 25, 50 supp
4, 8mg; 4, 8mg ODT
Appr
oved
Gastrointe
stinal
Compazine
(tablet/suppositor
y)
Phenergan
(tablet/syrup/sup
pository)
Zofran
Gastrointe
stinal
Anti-Emetic; Prokinetic
metoclopramide syrup
5, 10mg; 5mg/5ml
120ml
Appr
oved
Gastrointe
stinal
Anti-Inflammatory Agents
Reglan
(tablet/syrup/solu
tion)
Apriso ER
mesalamine
375mg
Gastrointe
stinal
Azulfidine
sulfasalazine
500mg
Not
appro
ved
Appr
oved
Gastrointe
stinal
Colazal
balsalazide
750mg
Gastrointe
stinal
Pentasa
mesalamine
250, 500mg
ondansetron
Appr
oved
Appr
oved
Not
appro
ved
Not
appro
ved
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
PAP
Nonformula
ry
Available to
CommUnityCare
prescribers only.
Email *PAP for
override. Not
available to other
prescribers.
Gastrointe
stinal
Proctozone rectal
cream
hydrocortisone
2.50%
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Central
Pharma
cy
Gastrointe
stinal
Anti-Spasmodics
Bentyl
dicyclomine
10mg, 20mg;
10mg/5ml
Appr
oved
Gastrointe
stinal
Anti-Spasmodics
Donnataltab/elixir
atropine/scop/hyoscy/ph
enobarb
16.2mg, 48.6mg
Appr
oved
Gastrointe
stinal
Anti-Spasmodics
Levsin
hyoscyamine S.L.
0.125mg
Appr
oved
Gastrointe
stinal
Anti-Spasmodics
Levsinex , etc
hyoscyamine SR
0.375mg
Appr
oved
Gastrointe
stinal
Anti-Spasmodics
Librax
clidinium
/chlordiazepoxide
5-2.5mg
Appr
oved
Gastrointe
stinal
Antiulcer Agents
Carafate
sucralfate
1g
Appr
oved
Gastrointe
stinal
Antiulcer Agents
Cytotec
misoprostol
100mcg, 200mcg
Appr
oved
Gastrointe
stinal
Antiulcer Agents, H.Pylori
PrevPac
lansoprazole/amoxicilli
n/clarithromycin
30/500/500mg
Appr
oved
Gastrointe
stinal
Antiulcer Agents, H.Pylori
Pylera
bismuth
subsalicylate/tetracyclin
e/metronidazole
140/125/125mg
Not
appro
ved
Nonformula
ry
Gastrointe
stinal
Anti-Ulcer Agents, Histamine
H2 Antagonist
Pepcid
famotidine
20mg, 40mg
Appr
oved
Gastrointe
stinal
Anti-Ulcer Agents, Histamine
H2 Antagonist
Zantac
ranitidine
150, 300mg
Appr
oved
Gastrointe
stinal
Antiulcer Agents, Proton
Pump Inhibitor
Aciphex
rabeprazole
20mg
Gastrointe
stinal
Pump Inhibitor
Dexilant
dexlansoprazole
60mg
Not
appro
ved
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
PAP
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Amoxicillin/Clarit
hromycin/Pantopr
azole is preferred
Pantoprazole
preferred
Gastrointe
stinal
Pump Inhibitor
Nexium
(capsule/suspensi
on)
esomeprazole
20, 40mg capsule;
10, 20, 40mg oral
suspension
Appr
oved
Central
Pharma
cy
Gastrointe
stinal
Pump Inhibitor
Protonix
pantoprazole sodium
20mg, 40mg
Appr
oved
Gastrointe
stinal
Cholinergic Antagonist
Robinul, Robinul
Forte
glycopyrrolate
1, 2mg
Gastrointe
stinal
Corticosteroid, Rectal
Anusol HC
suppository
hydrocortisone acetate
25mg
Not
appro
ved
Appr
oved
Retail
Networ
k
PAP
Gastrointe
stinal
Cortenema
hydrocortisone enema
100mg/60ml
Appr
oved
Gastrointe
stinal
Cortifoam
hydrocortisone foam
10%
15g
Appr
oved
Gastrointe
stinal
Digestive Enzymes
Creon
pancrelipase
6000, 12000, 24000
units
Appr
oved
Gastrointe
stinal
Digestive Enzymes
Pancreaze
pancrelipase
4200, 10500, 16800,
21000 units
Appr
oved
Gastrointe
stinal
Digestive Enzymes
Zenpep
pancrelipase
5000, 10000, 15000,
20000 units
Appr
oved
Gastrointe
stinal
Gallstone dissolution agent
Urso
ursodiol
250, 300mg
Appr
oved
Gastrointe
stinal
Laxative
Amitiza
lubiprostone
8, 24mcg
Gastrointe
stinal
Laxative
PEG-3350/electrolytes
236-22.74G, 227.121.5G, 240-22.72G
Genitourin
ary Tract
5-Alpha-Reductase
Inhibitor/Alpha-1 adrenergic
Blocker
5-Alpha-Reductase Inhibitors
Golytely,
Gavilyte C,
Gavilyte N,
Gavilyte G
Jalyn
Not
appro
ved
Appr
oved
dutasteride/tamsulosin
0.5/0.4mg
Avodart
dutasteride
0.5mg
Genitourin
ary Tract
Genitourin
ary Tract
5-Alpha-Reductase Inhibitors
Proscar
finasteride
5mg
Genitourin
ary Tract
Alpha-1 adrenergic Blocker
Flomax
tamsulosin
0.4 mg
Not
appro
ved
Not
appro
ved
Appr
oved
Appr
oved
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Retail
Networ
k
PAP
Finasteride is
preferred
PAP
Finasteride is
preferred
Retail
Networ
k
Retail
Networ
k
Genitourin
ary Tract
Rapaflo
silodosin
4, 8mg
Not
appro
ved
Not
appro
ved
Appr
oved
PAP
Tamsulosin is
preferred
Genitourin
ary Tract
Uroxatral
alfuzosin
10mg
PAP
Tamsulosin is
preferred
Genitourin
ary Tract
Analgesic
Pyridium
phenazopyridine
100, 200mg
Genitourin
ary Tract
Incontinence
Detrol
tolterodine tartrate
1, 2mg
Appr
oved
Genitourin
ary Tract
Incontinence
Detrol LA
tolterodine
2, 4mg
Appr
oved
Central
Pharma
cy
Genitourin
ary Tract
Incontinence
Ditropan XL
oxybutynin
5, 10, 15mg;
5mg/5ml
Not
appro
ved
PAP
Genitourin
ary Tract
Incontinence
Enablex
darifenacin
7.5mg
Not
appro
ved
PAP
Genitourin
ary Tract
Incontinence
Toviaz
fesoterodine extendedrelease
4, 8mg
Appr
oved
Central
Pharma
cy
Genitourin
ary Tract
Incontinence
Urecholine
bethanechol
5, 10, 25, 50mg
Appr
oved
Genitourin
ary Tract
Incontinence
Vesicare
solifenacin
5, 10mg
Not
appro
ved
Retail
Networ
k
PAP
Retail
Networ
k
Central
Pharma
cy
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Detrol or Detrol
LA is preferred for
CommUnityCare
prescribers. Other
prescribers must
enroll in PAP
Detrol or Detrol
LA is preferred for
CommUnityCare
prescribers. Other
prescribers must
enroll in PAP
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Detrol or Detrol
LA is preferred for
CommUnityCare
prescribers. Other
prescribers must
enroll in PAP
Genitourin
ary Tract
Elmiron
pentosan polysulfate
sodium
100mg
Not
appro
ved
Appr
oved
PAP
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Adrenals
Decadron
(tablet/elixir)
dexamethasone
0.5, 1, 2, 4mg;
0.5mg/5ml
Adrenals
Florinef
fludrocortisone
0.1mg
Appr
oved
Retail
Networ
k
Androgens
Androgel 1%
Packet
testosterone 1% gel
packet
1%(25mg)
Appr
oved
Retail
Networ
k
Androgens
DepoTestosterone
testosterone
200mg/ml 1ml inj
Not
appro
ved
PAP
Anti-Neoplastics
Femara
letrozole
2.5mg
Appr
oved
Retail
Networ
k
Antithyroid Agents
Tapazole
methimazole
5, 10mg
Appr
oved
Retail
Networ
k
Corticosteroids
Cortef
hydrocortisone
5, 10, 20mg
Appr
oved
Retail
Networ
k
Corticosteroids
Delta-Cortef
prednisolone
5mg
Appr
oved
Retail
Networ
k
Corticosteroids
Deltasone
prednisone
1, 2.5, 5, 10, 20,
50mg
Appr
oved
Retail
Networ
k
Corticosteroids
Medrol
methylprednisolone
4mg (Dosepak #21)
Appr
oved
Retail
Networ
k
Retail
Networ
k
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Corticosteroids
Medrol
methylprednisolone
4mg
Appr
oved
Retail
Networ
k
Corticosteroids
Prelone
prednisolone oral liquid
15mg/5ml
Appr
oved
Retail
Networ
k
Estrogens
Estrace
estradiol, micronized
tablet
0.5, 1, 2mg
Appr
oved
Retail
Networ
k
Estrogens
Estrace Vaginal
Cream
estrogens, conjugated
vaginal cream
0.01% (42.5g tube)
Not
appro
ved
Nonformula
ry
Estrogens
Premarin
0.625, 1.25mg
Appr
oved
Retail
Networ
k
Estrogens
Premarin Vaginal
Cream
vaginal cream
0.625mg/g (42.5g
tube)
Appr
oved
Retail
Networ
k
Estrogens
Prempro
medroxyprogesterone
acetate/estrogen
1.5/0.3, 1.5/0.45,
2.5/0.625,
5/0.625mg
Appr
oved
Retail
Networ
k
Hormonal Contraceptives,
non-oral
Nuvaring
Ethinyl Estradiol
0.15mg/day,
Etonogestrel
0.12mg/day
box
Appr
oved
Central
Pharma
cy
Hormones
&
Synthetic
Substitute
s
oral
Enpresse, Trivora
28 tablets
Appr
oved
Retail
Networ
k
Hormones
&
Synthetic
oral
Levora, Nordette
28, Portia 28
Ethinyl Estradiol
0.03mg, Ethinyl
Estradiol 0.04mg,
Levonorgestrel 0.05mg,
Levonorgestrel
0.075mg,
Levonorgestrel
0.125mg
Ethinyl Estradiol
0.03mg, Levonorgestrel
0.15mg
28 tablets
Appr
oved
Retail
Networ
k
Premarin Vaginal
Cream preferred
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
oral
Necon 1/35,
Norinyl 1/35,
Nortrel 1/35,
Ortho-Novum
1/35
Ortho Micronor,
Camila, Errin,
Heather,
Jencycla,
Jolivette, Lyza,
Nor-QD, Nor-BE
Ortho-Cyclen,
Mononessa,
Sprintec
Ethinyl Estradiol
0.035mg,
Norethindrone 0.5mg
28 tablets
Appr
oved
Retail
Networ
k
Norethindrone 0.35mg
28 tablets
Appr
oved
Retail
Networ
k
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
oral
Ethinyl Estradiol
0.035mg, Norgestimate
0.25mg
28 tablets
Appr
oved
Retail
Networ
k
oral
Ortho-Novum
7/7/7, Necon
7/7/7, Nortrel
7/7/7
28 tablets
Appr
oved
Retail
Networ
k
oral
Ortho-Tri-Cyclen
LO
28 tablets
Appr
oved
Retail
Networ
k
oral
Ortho-TriCyclen, Trinessa,
Tri-Sprintec
28 tablets
Appr
oved
Retail
Networ
k
oral
Sronyx, Aviane,
Lutera, Orsythia
Ethinyl Estradiol
0.035mg,
Norethindrone 0.5mg,
Norethindrone 0.75mg,
Norethindrone 1mg
Ethinyl Estradiol
0.25mg
Ethinyl Estradiol
0.25mg
Ethinyl Estradiol
0.02mg, Levonorgestrel
0.01mg
28 tablets
Appr
oved
Retail
Networ
k
oral
Yasmin 28-Day
Tablet
Ethinyl Estradiol
0.03mg, Drospirenone
3mg
28 tablets
Appr
oved
Retail
Networ
k
Parathyroid agent
Miacalcin
calcitonin-salmon (nasal
spray)
200 units/actuation
(2mL)
Appr
oved
Retail
Networ
k
Pituitary hormone, nasal
DDAVP
desmopressin acetate
(nasal spray)
0.01mg (5mL)
Appr
oved
Retail
Networ
k
oral
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Hormones
&
Synthetic
Substitute
s
Immunolo
gic Agents
Pituitary hormone, systemic
DDAVP
desmopressin acetate
(tablet)
0.1mg, 0.2mg
Appr
oved
Retail
Networ
k
Progestins
Aygestin
norethindrone acetate
5mg
Appr
oved
Retail
Networ
k
Progestins
Prometrium
progesterone
100mg
Not
appro
ved
PAP
Progestins
Provera
medroxyprogesterone
2.5, 5, 10mg
Appr
oved
Retail
Networ
k
Selective Estrogen Receptor
Modulator
Evista
raloxifene
60mg
Appr
oved
Retail
Networ
k
Thyroid Agents
Cytomel
liothyronine
5, 25, 50mcg
Appr
oved
Retail
Networ
k
Thyroid Agents
Levothroid
levothyroxine
25, 50, 75, 88mcg
Appr
oved
Retail
Networ
k
Thyroid Agents
Levoxyl
levothyroxine
25, 50, 75, 88, 100,
112, 125, 137, 150,
175, 200, 300mcg
Appr
oved
Retail
Networ
k
Immunomodulators
Pegasys
peginterferon alpha-2a
180mcg/ml
PAP
Immunolo
gic Agents
Immunomodulators
Pegintron
peginterferon alpha-2b
120, 150mcg/0.5ml
Immunolo
gic Agents
Immunosuppresants
Prograf
tacrolimus
1, 5mg
Immunolo
gic Agents
Immunosuppresants
Rapamune
sirolimus
1mg
Immunolo
gic Agents
Immunosuppressants
Cellcept
mycophenolate mofetil
250, 500mg;
200mg/ml
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
PAP
PAP
PAP
PAP
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
Not
appro
ved
Immunolo
gic Agents
Immunosuppressants
Neoral Capsule
cyclosporine
25, 100mg
Immunolo
gic Agents
Immunosuppressants
Neoral Liquid
cyclosporine
100mg/ml 50ml
Muscular
Agents
Chelating Agents
Chemet
succimer
100 mg
Musculos
kelatal
Agents
Anti-gout
Colcrys
colchicine
0.6mg
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Musculos
kelatal
Agents
Respirator
y Agents
Anti-gout
Uloric
febuxostat
40, 80mg
Anti-gout
Zyloprim
allopurinol
100, 300mg tablet
Bisphophonate
Actonel
risedronate
5, 30, 35mg
Appr
oved
Bisphophonate
Atelvia
risedronate
35mg
Appr
oved
Bisphophonate
Boniva
Ibandronate
150mg
Bisphophonate
Forteo Pen
teriparatide
750mcg/3ml
Bisphophonate
Fosamax
alendronate
5, 10, 35, 70mg
Not
appro
ved
Not
appro
ved
Appr
oved
Bisphophonate
Fosamax plus D
alendronate sodium/
cholecalciferol
70mg/2800 IU
Appr
oved
Antihistamine/ Antitussive
Phen Tuss DM
promethazine/
dextromethorphan syrup
6.25mg-15mg/5mL
Appr
oved
Respirator
y Agents
Antihistamine/ Antitussive
Tussionex
hydrocodone/
chlorpheneramine syrup
10mg-8mg/5ml
Appr
oved
Respirator
y Agents
Antihistamine/ Decongestant
Chlorpheniramine/
Pseudoephedrine tablet
4mg/ 60mg tablet
Appr
oved
Respirator
y Agents
Antihistamine/ Decongestant
Chlorpheniramin
e/
Pseudoephedrine
Phenergan VC
promethazine/
phenylephrine syrup
6.25mg-5mg/ 5ml
Appr
oved
Respirator
y Agents
Antitussive
Hydromet,
Mycodon
hydrocodone/
homatropine syrup
5mg-1.5mg/5ml
Appr
oved
Not
appro
ved
Appr
oved
PAP
PAP
PAP
Retail
Networ
k
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Nonformula
ry
PAP
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Limit 6 tablets per
month. Larger
quantities
available from
PAP.
Allopurinol is
preferred
Alendronate
preferred
Alendronate
preferred
Respirator
y Agents
Antitussive
Tessalon Perles
benzonatate gel caps
100, 200mg
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Respirator
y Agents
Antitussive/ Expectorant
Cheratussin AC
guaifenesin/codeine
syrup
100mg-10mg/5ml
Appr
oved
Respirator
y Agents
Antitussive/ Expectorant
Guaiatussin AC
guaifenesin/ codeine
syrup
100mg-10mg/5ml
Appr
oved
Respirator
y Agents
Antitussive/ Expectorant/
Decongestant
Cheratussin DAC
guaifenesin/codeine/pse
udofed syrup
100mg-10mg30mg/5ml
Appr
oved
Respirator
y Agents
Asthma Agents,
antiinflammatory
Zyflo
zileuton
600mg
Respirator
y Agents
Asthma Agents, mast cell
stabilizer
Intal
cromolyn inhaler
80mcg/inhalation
8.1g
Respirator
y Agents
Bronchodilator,
anticholinergic
Atrovent Inhaler
HFA
ipratropium oral inhaler
17mcg/actuation,
12.9g
Not
appro
ved
Not
appro
ved
Not
appro
ved
Respirator
y Agents
Bronchodilator,
anticholinergic
Combivent
Respimat
ipratropium/albuterol
20-100mcg/actuation
Not
appro
ved
PAP
Respirator
y Agents
Bronchodilator,
anticholinergic
ipratropium nebulizer
solution
(0.02%) 12 x 2.5mL
(nebulizer soluation)
Appr
oved
Respirator
y Agents
Bronchodilator,
anticholinergic
Ipratropium
nebulizer
solution
Spiriva
tiotropium bromide
18mcg
Not
appro
ved
Retail
Networ
k
PAP
Respirator
y Agents
Bronchodilator, beta-2 agonist
long
Foradil
formoterol
12mcg/actuation
Appr
oved
Central
Pharma
cy
Respirator
y Agents
long
Serevent diskus
salmeterol
50mcg
Not
appro
ved
PAP
PAP
PAP
CommUnityCare
prescribers email
*PAP for override.
Other prescribers
must enroll in
PAP.
CommUnityCare
prescribers
prescribe Proventil
and Atrovent
seperately. Other
prescribers must
enroll in PAP.
CommUnityCare
prescribers email
*PAP for override.
Other prescribers
must enroll in
PAP.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Foradil is
preferred but
available only to
CommUnityCare
prescribers. Other
prescribers must
enroll in PAP.
Respirator
y Agents
long
Serevent inhaler
salmeterol xinafoate
21mcg
Not
appro
ved
PAP
Respirator
y Agents
short
albuterol (nebulizer
solution)
2.5mg/3mL
(0.083%) 25x3ml
Appr
oved
Respirator
y Agents
short
Albuterol
(nebulizer
solution)
Albuterol (syrup)
albuterol (syrup)
2mg/5ml
Appr
oved
Respirator
y Agents
short
Albuterol (tablet)
albuterol (tablet)
4 mg
Appr
oved
Respirator
y Agents
short
Proventil HFA
albuterol HFA
6.7g
Appr
oved
Respirator
y Agents
Bronchodilators, combination
Advair Diskus
fluticasone/salmeterol
DPI
100/50mcg,
250/50mcg,
500/50mcg
Not
appro
ved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
PAP
Respirator
y Agents
Advair HFA
fluticasone/salmeterol
MDI
45/21, 115/21,
230/21mcg
Not
appro
ved
PAP
Respirator
y Agents
Dulera
mometasone/formoterol
100/5mcg,
200/5mcg/actuation
Appr
oved
Central
Pharma
cy
Respirator
y Agents
Symbicort
budesonide/formoterol
80/4.5mcg,
160/4.5mcg
Appr
oved
Central
Pharma
cy
Respirator
y Agents
Corticosteroid, Inhaled
Aerobid
flunisolide HFA
160mcg
Not
appro
ved
PAP
Foradil is
preferred but
available only to
CommUnityCare
prescribers. Other
prescribers must
enroll in PAP.
Dulera is preferred
but only available
to
CommunityCare
prescribers. Other
prescribers must
enroll in PAP.
Dulera is preferred
but only available
to
CommunityCare
prescribers. Other
prescribers must
enroll in PAP.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Qvar is preferred
Respirator
y Agents
Asmanex
Twisthaler
mometasone
110, 220mcg
Appr
oved
Central
Pharma
cy
Respirator
y Agents
Flovent Diskus
fluticasone
50mcg
PAP
Respirator
y Agents
Flovent Rotadisk
fluticasone
50, 250mcg
PAP
Qvar is preferred
Respirator
y Agents
Flovent; Flovent
HFA
fluticasone oral inhaler
44, 110, 220mcg
PAP
Qvar is preferred
Respirator
y Agents
Pulmicort
Flexhaler
budesonide
90, 180mcg
Not
appro
ved
Not
appro
ved
Not
appro
ved
Appr
oved
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Qvar is preferred
Central
Pharma
cy
Respirator
y Agents
Pulmicort
Respules
budesonide
dipropronate suspension
0.25, 0.5, 1mg/2ml
PAP
Respirator
y Agents
Pulmicort
turbohaler
budesonide
200mcg
PAP
Qvar is preferred
Respirator
y Agents
QVAR
beclomethasone HFA
40, 80mcg
Not
appro
ved
Not
appro
ved
Appr
oved
Restricted to
CommUnityCare
prescribers, Send
RX to
CommUnityCare
Central Pharmacy.
Not available to
other prescribers.
Qvar is preferred
Respirator
y Agents
Leukotriene Receptor
Antagonists
Singulair
montelukast
10mg tablet
Appr
oved
Respirator
y Agents
Theophyllines
Theodur
theophylline ER
100, 200, 300mg
Appr
oved
Respirator
y Devices
Miscellaneous Resp Product
Aerochamber
Plus Flow-Vu
inhaler accessory
Respirator
y Devices
inhaler accessory
Respirator
y Devices
Aerochamber
Plus Flow-Vu
with Mask
Peak flow meter
Vaginal
Agents
Anti-Infective, Vaginal
clindamycin vaginal
cream
2% 40g
Appr
oved
Vaginal
Agents
Cleocin Vaginal
Cream
(Clindesse)
MetroGel
Vaginal
metronidazole vaginal
gel
0.75% 70g
Appr
oved
Appr
oved
large, medium, small
peak flow meter
Appr
oved
Appr
oved
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
Vaginal
Agents
Terazol 7
terconazole vaginal
cream
0.4%/45GM
Appr
oved
Vitamin D
Vitamin D Analogs
Drisdol
ergocalciferol (vitamin
D2)
50,000 units
Appr
oved
Vitamin D
Vitamin D Analogs
Rocaltrol
calcitriol
0.25, 0.5mcg
Appr
oved
Vitamin K
Vitamin K Analogs
Mephyton
phytonadione tablet
5mg
Appr
oved
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
Retail
Networ
k
MEDICATION OVERRIDE REQUEST FORM
To:
Pharmacy staff
Central Health
Request date:
FAX: 512-901-9763
Telephone: 512-978-8139
Number of pages:
From:
Prescribing Physician/Provider
Telephone number
Office Contact Person
Fax number
Instructions:
1. Complete the Medication Override Request From to request evaluation for nonformulary medications and interim fills.
2. Use a separate form for each request. Please attached any additional
supporting documentation.
3. Pharmacy staff will send a fax disposition back to the Office Contact Person.
MEMBER INFORMATION
Member ID:
DOB:
Last Name:
First name:
PREVIOUS MEDICATION THERAPIES FOR CONDITION (include notes and supporting
documentation).
1. Medication name:
Reason for change:
2.
Medication name:
Reason for change:
3.
Medication name:
Reason for change:
REQUESTED MEDICATION INFORMATION
Medication name:
Dose:
Duration:
Diagnosis:
Medical Necessity: ☐ Non-Formulary Medication ☐ Interim Fill ☐ Other
If other describe here:
FOR INTERNAL USE ONLY
APPROVAL:
☐ YES
☐ NO
rev: 01-07-2014
10. CLAIMS
CLAIMS
Provider should submit claims for services provided to MAP
enrollees to the appropriate payer. Central Health MAP is
responsible for primary care services, dental services, custom
orthotics, and selected specialty services. Seton Health Plan is
responsible for hospital-based and specialty services,
diagnostics, home health, and durable medical equipment
services.
For additional information, refer to other sections in this
handbook:
 See “Services and Authorizations.”
 See “Contract Providers.”
Central Health MAP
Seton Health Plan (SHP)
CLAIMS FOR Central Health MAP
Central Health MAP is responsible for primary care services, dental services, custom
orthotics, and selected specialty services. For additional information, refer to other
sections in this handbook:
Third Party Administrator (TPA): Valence
Submit Central Health MAP electronic claims to:
Valence Health
EDI Vendor ID: 36426
Submit Central Health MAP paper claims to:
Valence Health
P.O. Box 3869
Corpus Christi, Texas 78463
Claims processing:
Central Health MAP claims are processed as they are received.
Payment:
Check or Electronic Funds Transfer (EFT) is made by Central Health.
Explanation of Payments (EOP):
Central Health will send a corresponding EOP to the provider.
 See additional EXAMPLE document entitled “Explanation of Payments.”
Appeals:
 See additional document entitled “Central Health Claim Reconsideration
Face Sheet.”
Claims for Central Health MAP
Page 1 of 2
Revised 09/15/2011
Claims Reconsiderations and Appeals:
Central Health MAP electronic claims to:
Valence Health
Central Health MAP paper claims to:
Valence Health
P.O. Box 3869
Claims for Central Health MAP
Page 2 of 2
Revised 09/15/2011
CLAIM RECONSIDERATION FACE SHEET
Date:
To: Central Health Map Electronic Claims
Valence Health
From:
Central Health MAP Paper Claims
Valence Health
P.O. Box 3869
Phone:
Fax:
Member Name:
Member ID#
Claim #:
State Reason for Reconsideration:
Attachments are required for reconsideration review.
Check Appropriate Reason:
□
No Authorization — Requesting Retro-Authorization
□
History & Physical/Office Notes
□
□
Discharge Summary
UB92/HCFA
State reason no auth obtained:
□
Processed as Inpatient vs. Observation stay
□
□
□
History & Physical
Copy of physician’s order for observation
Past filing deadline
□
□
Valence Explanation of Benefits
Documentation with date of original submission to another carrier (certified mail receipt, other carrier’s
EOB, electronic filing report, etc.)
□
Reimbursement Adjustment
□
Valence Explanation of Benefits (EOB) or other payor EOB
Explanation:
□
□
□
Other:
UB92/HCFA
Explanation of Benefits
□
History & Physical/Office Notes
□
Discharge Summary
Central Health MAP
CLAIM RECONSIDERATION FACE SHEET
INSTRUCTIONS
1.
Each claim reconsideration is to be submitted in writing with the
“Claim Reconsideration Face Sheet” and supporting
attachments listed under each category “Reason for
Reconsideration.”
2.
Reconsideration’s and attachments can be mailed or
electronically submitted to:
□ Central Health MAP electronic claims to:
Valence Health
□ Central Health MAP paper claims to:
Valence Health
P.O. Box 3869
3.
Required fields to be completed:
□ Submitting person’s name, phone and fax number
□ Claim number
□ Reason for reconsideration
□ Applicable attachments
□ Member name and ID number
4.
Incomplete requests will result in claim reconsideration
rejection.
5.
Resubmissions and Claims Status Checks are not appeals.
Call Customer Service at 1-855-285-6MAP or 1-855-2856627 for claim status checks.
CLAIMS FOR SETON HEALTH PLAN
Seton Health Plan is responsible for hospital-based and specialty services,
diagnostics, home health, and durable medical equipment services. For additional
information, refer to other sections in this handbook:
Third Party Administrator (TPA): Mediview
Submit Seton Health Plan electronic claims to:
Availity (telephone 1-800-282-4548)
Payer ID: SHPMAP
Submit Seton Health Plan paper claims to:
SHP MAP
P.O. Box 14447
Austin, Texas 78761-4447
Claims processing:
Seton Health Plan claims are entered and processed as the claims are
received.
Payment:
Seton Health Plan checks are mailed every Wednesday.
Explanation of Benefits (EOB):
Seton Health Plan will send a corresponding EOB to the provider at the time
payment is issued.
Appeals:
 See additional document entitled “Seton Health Plan Claim
Reconsideration Face Sheet.”
Provider Handbook
11. FREQUENTLY ASKED QUESTIONS
Provider Handbook
FREQUENTLY ASKED QUESTIONS
MAP Enrollment
Who may quality for MAP?
o Travis County residents with family incomes at or below 100 percent of
the Federal Poverty Index Guidelines (FPIG), who meet asset
guidelines, and have no other health care coverage (such as Medicaid
or Medicare).
o Travis County residents who are disabled or elderly with incomes at or
below 200 percent of the Federal Poverty Index Guidelines, who meet
asset guidelines, and have no other health care coverage (such as
Medicaid or Medicare).
o Travis County residents with Medicaid or Medicare will not qualify for
MAP benefits. Persons who do not qualify for MAP may be eligible for
other programs that offer health care services at reduced rates.
What color is the MAP card?
The MAP card is pink.
What is the length of issuance for MAP coverage?
The length of issuance for MAP coverage may range from one month to
one year and is dependent on the enrollee’s circumstances as determined
during the enrollment process.
What if an enrollee lost her/his MAP card?
978-8130 or to the eligibility office nearest her/his home to obtain a
replacement MAP identification card.
To verify coverage, visit the Provider Self Service website.
Frequently Asked Questions
Page 1 of 3
Revised 07/25/2013
Provider Handbook
What if an enrollee wants to report a change of address?
978-8130 or to the eligibility office nearest her/his home to report a change
of address.
Coverage Verification
How do I verify MAP coverage and co-payments?
Providers can verify an enrollee’s MAP information on-line using the
Provider Self-Service website. You will find instructions on how to register
for the Provider Self-Service, and reading the MAP ID card in this
handbook.
What if an enrollee has expired MAP coverage?
Enrollees are encouraged to call the Customer Service Call Center at (512)
978-8130 or to visit an eligibility office two to three (2-3) weeks in advance
of her or his MAP expiration date to schedule an enrollment/eligibility
appointment.
Pharmacy Services
Which pharmacies are in the MAP network?
The list of MAP network pharmacies is included in this handbook. For
additional information contact the MAP Pharmacy hotline at (512) 9788139.
What medications are covered by MAP?
MAP covers most medications needed by enrollees. The MAP Formulary is
included in this handbook. For additional information contact the MAP
Pharmacy hotline at (512) 978-8139.
Page 2 of 3
Revised 07/25/2013
Provider Handbook
What if the enrollee cannot tolerate generic or formulary
medications?
The provider may submit a Medication Override Request Form on the
enrollee’s behalf. For additional information contact the MAP Pharmacy
hotline at (512) 978-8139.
Where can I get the Medication Override Request Form?
The form is included in this handbook. For additional information contact
the MAP Pharmacy hotline at (512) 978-8139.
What can I do if I receive calls from enrollees about pharmacy
services?
All callers inquiring about pharmacy services should be directed to the
MAP Pharmacy Hotline at (512) 978-8139.
What if the enrollee is not satisfied with treatment or medical care?
Please encourage enrollees to discuss any concerns or questions about
her or his treatment or medical care with his/her primary care provider. If
the enrollee is unable to resolve issues with the primary care office, please
give the enrollee our telephone number (512) 978-8150.
Page 3 of 3
Revised 07/25/2013
Provider Handbook
12. QUICK REFERENCE: CONTACTS AND HELPFUL NUMBERS
QUICK REFERENCE: CONTACTS AND HELPFUL NUMBERS
Claims and/or Appeals (Electronic)
Valence Health
Claims and/or Appeal (Paper)
Valence Health
P.O. Box 3869
Claims Customer Service
Telephone: 1-855-285-6MAP
1-855-285-6627
Central Health
1111 East Cesar Chavez Street
Austin, Texas 78702
Telephone: (512) 978-8000
www.centralhealth.net
Central Health Customer Service
Telephone: (512) 978-8130
Credentialing Questions
Telephone: (512) 978-8008
MAP Enrollment
Call the Customer Service Call Center
(512) 978-8130 for information
MAP Eligibility Verification
Online: Provider Self Service or
Telephone: 512-978-8130
MAP Benefits Verification
Online: Provider Self Service or Telephone: 512-978-8130
MAP Pharmacy Hotline
Telephone: (512) 978-8139
Fax: (512) 901-9763
MAP Case Managers
Telephone: (512) 978-8100
Fax: (512) 901-9724
Seton Health Plan
Medical Management Nursing: (512) 324-3135
Member Services: 1-866-272-2507
Sendero Utilization Management
Fax: (512) 901-9724
Sendero Network Management (Provider Relations)
Telephone: (512) 978-8010
Fax: (512) 901-9704
Bus Service (public transportation)
Capital Metro: (512) 474-1200
CARTS: (512) 478-7433
Contact Provider Relations
512-978-8010
for questions, comments, or corrections.
MAP Contact Information
For Services Rendered
On and After October 1, 2011
Department
Benefits Verification
Phone/Fax
512-978-8130
Claims and/or Appeals (Electronic)
Valence Health
Claims and/or Appeals (Paper)
Valence Health
P.O. Box 3869
Corpus Christi, TX 78463
Claims Customer Service
1-855-285-6MAP
1-855-285-6627
Credentialing
512-978-8008
Eligibility Verification
512-978-8130
Health Service – authorization and
medical management
512-978-8100
Secure Fax: 512-901-9724
Provider Relations
512-978-8010
Seton MAP
The Seton Family of Hospitals and Seton Health Plan relationship continues to manage the
hospital based and specialty care services. Please contact Seton Health Plan for all hospital based
and specialty care services: Authorizations 512-324-3135 and Claims Customer Service 512-421-5664.
Provider Handbook
13. CommUnityCare
Women’s Health Center
FAX Transmittal -MAP Patients
1313 Red River, Suite 320, Austin, TX 78701
Fax- 512-279-7367
From Cl i ni c:
Fax:
Contact N ame:
Contac t P hone:
P ages ( i ncl udi ng f ax transmi ttal )
Re:
NOTE: Appointment information will be faxed to the PCP clinic within 72 business hours of
receiving a completed referral with all pertinent documentation. The PCP clinic is responsible
for notifying the patient of the specialty appointment.
Comments:
The information contained in this facsimile message is legally privileged and confidential
information intended only for the use of the entity named above. If the reader of this
transmission is not the intended recipient, you are hereby notified that any
dissemination, distribution or copying of this transmission is strictly prohibited. If you
received this transmission in error, please immediately notify us by telephone to arrange
for return of the original documents.
CommUnityCare Women’s Health Center
Professional Office Building
1313 Red River, 3rd Floor, Suite 320
(512) 978-8870
□ From the 2nd Floor of the Parking Garage, pass the parking garage elevators and
turn right.
□ Go down a short hallway until you get to the automatic doors.
□ When you enter through the automatic doors, you will be located on the 2nd Floor
of the Professional Office Building.
□ Take the elevador to the 3rd Floor.
□ As you come out of the elevator, turn right and then at the corner turn right again to
get to the CommUnityCare Women’s Health Center (Suite 320).
□ Enter through the door and sign in at the check-in desk.
Elevator
Clinical Education Center (CEC)
Labor & Delivery
Brackenridge
Employee Elevators
Chapel
Public
Elevator
Public
Elevator
Information
Desk
Gift Shop
Second
Floor
Coffee Shop
Parking Garage
W
A
L
K
W
A
Y
Professional Office Building
CommUnityCare
Suite 320
YOU ARE
HERE
2
nd
Floor
Parking Garage Elevators
ENTER ON 2nd Floor
3rd Floor
Elevator
Go up to Restroom
3rd Floor
CommUnityCare Centro de Salud para Mujeres
Edificio de Oficinas Profesionales
1313 Red River, Piso 3, Sala 320
(512) 978-8870
□ Desde Piso 2 del Estacionamiento, pase los elevadores del estacionamiento, y
dase una vuelta a la derecha.
□ Camine hasta que llega a la puerta automática.
□ Cuando entre por la puerta automática, usted estará en el Piso 2 del Edificio de
Oficinas Profesionales.
□ Tome el elevador hasta Piso 3.
□ Saliendo del elevador, dase una vuelta a la derecha y en la esquina otra vez a la
derecha para llegar a la ClInica de Embarazo y GinecologIa (Sala 320).
□ Entre por la puerta y presentese a la ventana de recepción.
Elevador
Centro de Educación Clinica (CEC)
Centro Universitario de Medicina
Brackenridge
Sala de Parto Elevadores de Empleados
Capilla
Elevador
Público
Elevador
Público
Información
Tienda de Regalos
Segundo
Piso
Cafeteria
Estacionamiento
P
U
E
N
T
E
Edificio de Oficinas Profesionales
CommUnityCare Women’s Health
Sala 320
USTED ESTA
AQUi
PISO 2
Elevadores del Estacionamiento
ENTRE EN Piso 2
Piso 3
Elevador
Suba a Bafios
Piso 3
CommUnityCare
Women’s Health
Brackenridge Professional Office Building
CommUnityCare — Women’s Health
Table of Contents
3
Genetic Counseling
4
Gynecology Clinic
5
Gynecology Clinic Worksheet
6
Gyn Procedures - LEEPs & Colpos
9
Obstetrics Clinic
10
Guidelines for Diabetes in Pregnancy
18
Appendix A
22
Appendix B
23
Appendix C
24
Ultrasounds — Level II
25
Pg. 2
Pg. 3
Genetic Counseling
Scope
□ Genetic Risk Assessment and Testing
□ Candidates for amniocentesis must be ≤ 20 weeks gestation on the day of their genetic
clinic appointment
□ Advanced Maternal Age (AMA): maternal age D 35 years old at delivery and patient consents
to an amnio; must watch video; see below.
□ Abnormal TAST screening test; amnio may or may not be indicated
□ Family history of birth defects, mental retardation, or genetic diseases
□ Personal history of birth defects, mental retardation, or genetic disease
□ Exposure to teratogens such as alcohol, drugs, and medications for maternal diseases (e.g.
Insulin-dependent diabetes). Patient may prefer to call Texas Teratogen Information Service
for free pregnancy exposure/risk counseling at 1-800-733-4727.
□ Abnormal ultrasound findings (fetal abnormalities)
□ Recurrent Pregnancy Loss (D 2 SAB)
□ Consanguineous matings
IMPORTANT! Before scheduling an appointment for genetic counseling, patient must
watch video titled, “Prenatal Diagnosis of Birth Defects: Amniocentesis”.
□ Completed referral form
□ Pertinent Lab results (TAST, hemoglobin electrophoresis, blood type, etc.)
□ Ultrasound report(s)
□ Title V Screening Document, if eligible
NOTE: Instruct patient to report to specialty clinic appointment no earlier than 15-30 minutes
prior to appointment time.
Pg. 4
Gynecology Clinic
Scope:
□ To evaluate moderate to highly complex gynecologic problems, and pre- & postsurgical patients.
□ Post-menopausal bleeding
□ Pelvic pain
□ Endometriosis
□ Missed AB & Threatened AB
□ Abnormal gynecological diagnoses
□ Pelvic Mass
□ Menometrorrhagia
□ Pelvic prolapse/urinary incontinence
Please do NOT refer the following patients to the Gyn clinic:
□ Desire for sterilization — Refer patient to AWH at 322-2100 for work-up and scheduling.
□ Infertility
□ Copy of recent documentation (i.e. chart notes)
□ Recently drawn labs, pap smear and gyn probe results
See worksheet on next page for more information.
Pg. 5
Gynecology Clinic Worksheet
1. Abnormal Pap/Colposcopy/LEEP—
a. ASCUS +HPV or higher (ASC-H, LGSIL, HGSIL, AGUS, CIS regardless of HPV)
b. Except:
□ If patient is 20 years or younger:
o ASC-US, LGSIL (regardless of HPV)—repeat Pap in 1 year
o If the repeat pap is ASC-US, LGSIL—repeat Pap again in 1 year
o If third pap has any abnormality, refer for colposcopy
□ Pregnancy
o We will now start deferring colpo on LGSIL and ASCUS paps until 8 weeks
Postpartum
o Refer ASC-H, AGUS, HGSIL, CIS at any time
c. Requires:
□ Results of Pap generating referral
□ Results of any previous abnormal paps, colposcopies and biopsies
□ Date of last known menstrual period
□ Last GC/CT (within the last year)
2. Abortion (Miscarriage)—
a. Threatened, incomplete, complete, missed, etc
b. Requires:
□ Type and Screen, CBC, Ultrasound, all known quant HCGs, last Pap and GC/CT
(within 1 year)
3. C-section staple removal—
a. For Pfannensteil skin incisions, the staples should be removed prior to hospital discharge. If
not, will be overbooked in next gyn clinic day.
b. For vertical skin incisions, these should be booked in the resident’s continuity clinic 7-10
days after the surgery was done.
BOTH OF THESE APPOINTMENTS SHOULD BE MADE BY THE RESIDENT AND
PLACED ON THE CHART PRIOR TO THE PATIENT’S DISCHARGE FROM THE
HOSPITAL.
c. If this is being generated by an outside source, requires:
□ Patient name and contact information
□ Location, date and type of surgery (C-section with or without BTL)
4.
Ectopic pregnancy—
a. Call L&D attending cell phone for further direction 450-3775
Pg. 6
G yn e c o l o g y C l i n i c W o r k s h e e t ( c o n t i n u e d )
5. Foley catheter following gyn surgery done at Brackenridge—
a. Should be scheduled by resident surgeon into resident’s continuity clinic prior to patient’s
discharge from hospital
b. If not, then should be scheduled into continuity clinic of the resident who did the surgery
c. If this is being generated by an outside source, requires:
□ Patient name and contact information,
□ Date, location of surgery, and type of surgery (as best can be determined)
6. Infertility—
a. We cannot accept patients for this referral.
b. Patients can be referred to Texas Fertility Center
7. IUD insertion—
a. We cannot accept patients for this referral.
b. Patients should be referred to primary care provider.
8. IUD removal—
a. Can be scheduled in gyn clinic;
b. If unable to be removed in gyn clinic, will require internal referral via Dr. Held for
treatment/removal at AWH.
c. Requires:
D Last note documenting reason for referral, last Pap and GC/CT, ultrasound if done (i.e.,
if there are not strings noted so that intrauterine placement can be determined)
9.
Molar Pregnancy—
a. Call L&D attending cell phone for further direction 450-3775
10. Post-Op D&Cs—
a. Should be scheduled in resident surgeon’s continuity clinic by the resident.
b. If not, is scheduled in resident surgeon’s continuity clinic
c. Requires (if referral from outside):
□ Patient name and contact information,
□ Date and location of surgery
Pg. 7
G yn e c o l o g y C l i n i c W o r k s h e e t ( c o n t i n u e d )
11. Postmenopausal Bleeding—
a. Vaginal bleeding after 6 months or more of amenorrhea
b. Requires:
□ Last Pap and GC/CT (within last year),
□ pelvic ultrasound,
□ CBC, TSH,
□ clinic notes discussing issue/referral
12. Pelvic Pain—
a. Requires:
□ All clinic notes addressing this issue
13. Endometriosis—
a. Requires:
14. Pelvic Mass—
a. Requires:
□ Copies of any imaging studies done,
15. Menometrorrhagia—
a. Requires:
□ CBC, TSH,
16. Pelvic Prolapse/Urinary Incontinence—
a. Requires:
□ UA with C/S,
□ Clinic notes addressing this issue
17. Sterilization—
a. We do not accept referrals for this; refer these patients to AWH 322-2100
Pg. 8
Gyn Procedures - LEEPs & Colpos
Scope
□ To perform LEEPs and Colpos.
Appropriate patients for referral into Gyn Procedures include:
□ Abnormal PAP results
□ Cervical Dysplasia
□ Pap results
□ Biopsy results
□ Gen probe
□ Colpo Target Sheet or NextGen GYN Colposcopy document (needed for LEEPs only)
Pg. 9
Obstetrics Clinic
(OB High Risk, OB Diabetes and OB Testing)
Scope:
□ To evaluate high-risk obstetric patients.
□ Hypertension (Chronic or Pregnancy Induced)
□ Diabetes — refer to OB Diabetic Clinic on Mondays if diabetes management is desired.
Nutrition counseling without diabetic management is also available.
□ History of spontaneous abortions or premature births
□ Placenta Previa / Preterm Labor:
o If Suspected — refer to USG Clinic
o If Diagnosed w/ previous USG — refer to OB High Risk Clinic
□ Late Entry into Care (No prenatal care prior to 30 weeks gestation)
□ Multiple Gestation
□ Previous C-section
□ Large/small for dates — refer only after evaluated by an OB physician.
□ Post Date — refer to OB Testing Clinic
□ Cholestasis of pregnancy
□ Breech > 36 weeks
□ Medical disorders complicating pregnancy including:
o AIDs/HIV positive
o Thyroid Disorder
o Renal Disorder
o Drug Dependence
o Lupus
o Seizure Disorder
□ ACOG (IOB) Forms
□ Results of recent labs and pathology results (i.e. pap smears and biopsies)
See worksheet on next page for more information
Pg. 10
Obstetrics Clinic Worksheet
1. Abnormal TAST—
a. Needs an ultrasound to confirm dates
□ If dates confirmed, then referral is to genetics to discuss amniocentesis
□ Genetics can only be scheduled if gestation is <20 weeks
b. Requires:
□ IOB and master EMR copy (which includes all prenatal visits and info to date),
□ all prenatal labs (including Pap and GC/CT),
□ results of abnormal TAST,
□ copy of ultrasound confirming dates
2. Amniocentesis—(For AMA or other genetics reasons, requires genetics referral)
a. Genetics can only be scheduled if gestation is <20 weeks
b. Requires:
□ all prenatal labs (including TAST if done),
□ Pap and GC/CT,
□ copy of ultrasound (if done)
3. C-section scheduling—(if does not meet dating criteria)
a. Previous C-section-b. Requires:
□ copy of any ultrasounds
4. Anatomy scan (Level II Ultrasound or Targeted Ultrasound)—
a. Reserved for patients with concerns on routine scan done at NE, HROB, or at a radiology
facility (ie ARA)
b. If for AMA, patient should see genetics first, and must be sent before 20 weeks gestation.
c. Requires:
□ IOB and master EMR coy (which includes all prenatal visits and info to date),
□ copy of ultrasound generating referral
Pg. 11
Obstetrics Clinic Worksheet (continued)
5. Diabetes (pregnant)—
a. See Guidelines for Diabetes in Pregnancj at end of Obstetrics Clinic Worksheet.
b. Known diagnosis of diabetes prior to pregnancy (please send information on how long
patient has been a diabetic, pre-pregnancy medications and treatment, pre-pregnancy
diabetes complications, and last hemoglobin A1C (done within the last 3 months)
c. Requires:
□ IOB
□ all prenatal labs
□ copy of ultrasound (to document viability or if before viability, all quantitative HCGs)
□ results of GTT testing, hemoglobin A1C, with information as noted below in
□ if known diabetic, 24 hour urine for protein and creatinine clearance, TSH, free
T4, TAST (if appropriate)
6. Genetics—
a. AMA; abnormal TAST; family history of birth defects, mental retardation, or genetic
diseases; personal history of birth defects, mental retardation or genetic disease; exposure to
teratogens, abnormal ultrasound findings, recurrent pregnancy loss (2 or more),
consanguineous mating
b. Requires:
□ all prenatal labs (including TAST, hemoglobin electrophoresis, Pap,
GC/CT),
□ documentation of specific reason for referral and all supporting
information,
□ copy of any ultrasounds done
7. NST—
a. Postdates pregnancy (41 wks) or A1 (diet controlled) GDM (40 weeks)
b. Done on Mon, Tues, Thurs and Fri (Mon, Thurs, Fri preferred)
c. Requires:
□ all prenatal labs including Pap, GC/CT, GBS and date of its collection,
□ copy of all ultrasounds
8. Pregnancy and Hypertension (Chronic or Pregnancy Induced)—
a. Requires:
□ Prenatal labs (including Pap and GC/CT), TSH, Free T4, 24 hour urine for
creatinine clearance and total protein
Pg. 12
9. History of 2 or more spontaneous abortions (<14 wks)—
a. Genetics referral (see above);
b. Send Lupus Anticoagulant and Anticardiolipin Antibodies; if abnormal, then refer.
c. Requires:
□ prenatal labs (including Pap and GC/CT),
□ abnormal lab results as above
10. Pregnancy and history of previous second trimester loss (14-24 weeks)—
a. Send Lupus Anticoagulant and Anticardiolipin Antibodies, Protein C, Protein S, Factor V
Leiden, Antithrombin III, MTHFR mutation
b. Requires:
□ prenatal labs (including Pap and GC/CT), lab results as above
11. Pregnancy and history of premature birth (24-36 weeks)—
a. Provide protection against recurrent preterm birth
b. Requires:
□ Singleton pregnancy 15-24 weeks with a documented previous delivery prior
to 37 weeks.
□ No multiple gestations known fetal anomaly, progesterone or heparin use in this
pregnancy, current or planned cervical cerclage, CHTN requiring medication,
seizure disorder, delivery planned outside of Brackenridge or AWH.
□ Ultrasound required between 14 and 20-6/7 weeks to confirm dating and identify
major fetal abnormalities.
□ Must sign release of information to obtain records from previous pregnancy ending
in preterm delivery (singleton between 20 and 36-6/7 weeks gestation due to
spontaneous preterm labor or PPROM).
□ Patient must be willing to attend weekly appointments at HROB and receive
weekly progesterone shots from 24-37 weeks of pregnancy
□ copy of all ultrasounds
Pg. 13
1. Placenta Previa—
a. Confirmed by ultrasound between 24-28 weeks of gestation
b. Requires:
□ copies of all ultrasounds;
□ DO NOT COLLECT PAP AND GC/CT IF NOT DONE PRIOR TO 24-28
WEEK DIAGNOSIS
2. Multiple gestation—
a. Confirmed by ultrasound (we must have a copy of this ultrasound)
b. Requires:
□ copies of all ultrasounds
3. Large/small for dates—
a. Only refer once confirmed by OB physician; Fundal height must be more than 3 cm off of
gestational age
b. Requires:
□ OB and master EMR copy (which includes all prenatal visits and info to date),
□ ultrasound done (either by ARA or NE) confirming <10% EFW for gestational age,
>90% EFW for gestational age, AFI<5cm or AFI >25cm
4. Cholestasis of pregnancy—
a. Pruritis without skin changes; Elevated liver function tests; Elevated fasting bile acids
b. Requires:
□ Pruritis without skin changes with either (or both) elevated liver function
tests or elevated fasting bile acids
□ copies of abnormal labs,
□ copies of any ultrasounds
5. Breech >36 weeks—
a. Requires:
□ copies of any ultrasounds
Pg. 14
6. HIV/AIDS and pregnancy—
a. Requires:
□ most recent viral load and CD4 count,
□ Hepatitis C antibody,
□ any ultrasounds,
□ copies of last clinic notes detailing disease diagnosis, co-morbid conditions or
defining illnesses and treatment
7. Thyroid disorder and pregnancy—
a. Requires:
□ all prenatal labs (including Pap and GC/CT), TSH, Free T4,
□ any ultrasounds,
□ copies of last clinic notes detailing thyroid disease diagnosis and duration of disease
and treatment,
□ copy of last endocrine consultation if done.
8. Renal disorder and pregnancy—
a. Requires:
□ copy of any ultrasounds done (pregnancy or renal),
□ copies of last clinic notes detailing renal disorder/diagnosis, duration of disease
and treatment,
□ copy of last renal consultation if done,
□ 24 hour urine protein for creatinine clearance and total protein, CMP
(complete metabolic panel) with calcium and phosphorus
9. Drug Dependence and pregnancy—
a. Requires:
□ urine and serum drug screen results,
□ copy of any ultrasounds done,
□ copies of last clinic notes outlining drugs of use/abuse and duration as well as
past treatment
Pg. 15
10. Lupus and pregnancy—
a. Requires:
□ 24 hour urine for creatinine clearance and total protein,
□ ANA, anti-Ro and anti-La antibodies, CMP (complete metabolic panel) with calcium
and phosphorus,
□ copy of last clinic notes detailing diagnosis, duration of disease,
manifestations, treatment,
□ copy of last rheumatology consult if done
11. Seizure disorder and pregnancy—
a. Requires:
□ copy of last CT scan and EEG if done,
□ copy of last neurology consult if done, copy of any ultrasounds done
a. At time of recognition of need for referral, start patient on 4mg folic acid daily
12. Mental illness and pregnancy—
a. We do not accept referrals for this diagnosis. Please refer to MHMR or private psychiatry.
If there are any questions regarding the safety of psychiatric medications in pregnancy, please
call the L&D cell phone (450-3775), and the appropriate follow-up can be arranged. Patient
may prefer to call Texas Teratogen Jnformation Service for free pregnancy exposure/risk
counseling at 1-800-733-4727.
13. Cardiac disease and pregnancy—
a. Requires:
□ last EKG if done,
□ last echo if done,
□ last cardiology consultation if done,
□ last clinic notes detailing diagnosis and treatment
Pg. 16
14. Hepatic disease and pregnancy—
a. Requires:
□ copy of any ultrasounds done, liver function tests, coagulation tests (PT, PTT,
INR), hepatitis panel,
□ last GI consultation if done,
□ last abdominal ultrasound if done,
□ last clinic notes detailing diagnosis and treatment
Pg. 17
Effective Date 7/1/11
*This document does not define a standard of care, nor is it intended to dictate an exclusive course
of management. There are other accepted strategies for the management of diabetes in pregnancy.
I.
Screening for gestational diabetes mellitus (GDM) (from Metzger BE, et al. Diabetes Care
2010, 33:676-681)
A. Universal screening at 24-28 weeks. If pregestational diabetes is present by history, then
screening is not necessary. Management will be with insulin. Further assessment as
described in Appendix A.
B. Selected screening early in pregnancy should be performed at the first prenatal visit.
1. Indications for select early screening:
a. History of gestational diabetes in a prior pregnancy
b. Previous macrosomic infant (>4000 gm)
c. Family history of diabetes in first degree relative
d. Obesity (BMI > 30)
e. Unexplained stillbirth in previous pregnancy
f. Maternal age at delivery to be > 35
2. Diagnostic Criteria for overt diabetes (to be measured on high risk women described
as above)
First prenatal visit
Measure AIC (this is the preferred method; others listed below)
To diagnose overt diabetes in pregnancy
Measure of glycemia
Consensus threshold
FPG‡
>7.0 mmol/l (126 mg/dl)
A1C‡
>6.5% (DCCT/UKPDS standardized)
Random plasma glucose
>11.1 mmol/l (200 mg/dl) + confirmations
* ‡One of these must be met to identify the patient as having overt diabetes in pregnancy. sIf a random plasma
glucose is the initial measure, the tentative diagnosis of overt diabetes in pregnancy should be confirmed by FPG
or A1C using DCCT/UKPDS-standardized assay
3. If overt diabetes is diagnosed, then treatment and follow-up as for preexisting
diabetes. Refer to High Risk OB (HROB).
4. If results are not diagnostic of overt diabetes and fasting plasma glucose >5.1
mmol/l(92 mg/dl) but <7.0 mmol/l (126 mg/dl), then diagnose as GDM.
Management as described in section II and III of this document. It the fasting
plasma glucose is <5.1 mmol/l (92 mg/dl), test for GDM from 24 to 28 weeks’
gestation with a 75-g OGTT
Pg. 18
G u i d e l i n e s f o r D i a b e t e s i n P r e g n a n c y ( C o n t i n u e d)
C. If the early screen at first prenatal visit is negative (<5.1 mmol/1 or <92 mg/dl), then repeat at
24-28 weeks. Screen with a 2hr 75gm oral glucose tolerance test (75gm OGTT)
D. Screen with 75 gm oral glucose tolerance test:
1. Diagnostic Criteria:
1.Positive screen when any one or more values is elevated
2. Method:
1.At least 8 hours of fasting prior to 75gm glucose screen
1. Fasting blood glucose followed by a 2 hour 75gm oral glucose
tolerance test
2.Plasma glucose at 1, and 2 hours after ingestion of glucose
3. Diagnosis of gestational diabetes: at least one abnormal value:
Fasting >
92 mg/dl
1 hour >
180 mg/dl
2 hour >
153 mg/dl
4. Diagnosis of overt diabetes if fasting plasma glucose is > 126 mg/dl. Refer to
HROB. Management with insulin and further assessment as described in
Appendix A.
II.
Management
A. Refer to Diabetes Education (see Appendix B for summary of education)
B. Diet
1. Arrange Nutritional counseling
2.IDEAL body weight (IDBW): 5 ft= 100lb. + 5lb. for every inch >5 ft.
3. Caloric intake: 30K cal/kg/day if body weight is IDBW +/- 20%.
This may be adjusted by dietician depending on body weight.
4. CHO, 40%; Protein, 20%- 30%; fat, 20%-30%.
5. 3 Meals and 2- 3 snacks daily.
C. Glucose monitoring four times daily: Fasting and 2hr glucose after breakfast, lunch
and dinner
D. Issue Glucometer and give education. A glucose log must be kept by patients. Check
fasting glucose and 2 hours after main meals (2 hr pc); four times daily. Record mean
fasting and mean 2 hr pc values each visit in the progress note.
E. If the mean fasting glucose is greater than 92 mg/dl, or the mean 2 hour post
prandial glucose is greater than 120 mg/dl, refer the patient to the High Risk
Obstetrics clinic within one week.
F. If the mean fasting glucose is greater than 120 mg/dl or if 2 hour glucose mean is
greater than 200 mg/dl then, this patient needs immediate evaluation. Consult with
the UMCB faculty at 512-450-3775.
Pg. 19
Guidelines for Diabetes in Pregnancj ( Continued)
III.
Therapy — women needing therapy other than diet should be referred to HROB.
A. Insulin (Humulin)
Initial calculation for total dose:
.8 units/kg/IBW daily — first trimester
.9 units/kg/IBW daily — second trimester
1.0 units/kg/IBW daily — third trimester
2/3 AM (3/4 NPH, ¼ Humalog) — @ breakfast
1/3 PM (1/2 NPH, ½ Humalog) — Humalog @ supper; NPH @ bedtime snack
B. Oral Agent Therapy — see Appendix C. In general this is reserved for gestational
diabetes only. Overt or preexisting diabetes should be managed with insulin in
almost all cases.
IV.
Antenatal Testing
A. A1 diabetes
Fetal movement chart at 36 weeks
NST twice weekly at 40 weeks
B. A2 diabetes (uncomplicated)
NST weekly at 32 weeks; twice weekly at 36 weeks
C. Pregestational or overt diabetes (uncomplicated)
Fetal movement chart at 28weeks
D. Diabetes complicated by hypertension, other evidence of vascular disease, renal or
eye involvement, or other significant medial or obstetric complications.
E. Other interventions and testing as indicated by clinical finding
V.
Delivery
A. Al diabetes at 4l weeks
B. Medically managed or insulin dependent diabetes 38.5 to 40 weeks depending on
control and patient reliability
C. Delivery prior to 38.5 week may require amniocentesis for pulmonary maturity,
unless an absolute indication for delivery based on maternal or fetal condition exists.
There is considerable controversy surrounding this issue.
Pg. 20
Appendix A
Early Assessment (< 20 weeks) - Overt or Pregestational Diabetes
MATERNAL
Physical Exam
Evaluate for:
HTN
Retinopathy
Goiter
Nephropathy
Possible Tests
Recommendation
EKG
Retinal evaluation
Ophthalmology Consult
T4, TSH 24 hr urine
Consult with appropriate
Collection for Cr. Cl. Medical or MFM consult if
and total protein, and required
urine culture
Obesity
Glucometer (test 4 times daily)
Glycemic Control
Nutritional Counseling
regarding obesity
Hb A1C
Diabetic Counseling
Dietician consult
FETAL
Gestational Age Assessment Physical Exam
Early ultrasound if possible
Anatomic Assessment
Appropriate fetal screening MFM Consult in all cases
(1st or 2nd trimester
ultrasound for dating)
MS-AFP at 15 0/7
(even if they had a 1st
trimester screening) This is
valid through 20 0/7 weeks
Targeted ultrasound at
18 -22 weeks for anatomy
Fetal echocardiogram at 24 weeks
Pg. 21
Appendix B
Guidelines for Diabetes Education
1.
Patients new to the OB Diabetic Clinic are provided education on Mondays, in a class
setting. Education is provided in the client’s primary language. The template is for 3 classes
of 4 patients each at 8:30am, 10:00 am and 11:30 am. Patients are instructed on importance
of good control of blood sugar during pregnancy, as well as possible complication with poor
control. Patients are encouraged to walk for exercise, unless medically prohibited. They are
also instructed on exercise precautions. They are instructed on use of the glucose log, timing
of testing for fasting and 2 hours after meals, and glucose logs. MAP patients are provided
with a Contour Meter and instructed in its use as well as in the use of the control solution.
Documentation is recorded in NextGen.
2.
Patients are counseled on a 2000 calorie Gestational Diabetes meal plan of 3 meals and 3
snacks. Reference materials are provided for the meal plan, food safety, risk reduction of
Type 2 Diabetes (when applicable) and healthy food habits for infants and children. Food
models are used to demonstrate sample meals, snacks and food portion sizes and patients
are evaluated on their knowledge of foods high in carbohydrates. Patients are also provided
with a 1 week food log to record their intake and are asked to return it at their next clinic
visit. The dietitian will review the food log with the patient and provide feedback.
Documentation is recorded in NextGen.
3.
Tuesdays, the dietitian and nurse educator are available in the clinic to follow up on patients
taught the previous week in class, to teach patient needing Glyburide or insulin and to see
any patients referred by the physician. We like to follow up with any patients who have been
discharged from the hospital.
4.
Please order insulin dose in increments of 2. We try to teach all patients needing insulin on
the 1 cc insulin syringes which are marked only in 2’s, so even numbers of insulin can
confusing to our clients.
Pg. 22
Appendix C
Oral Agent Therapy for Gestational Diabetes (NEJM 2OOO: 343:1134-8)
Hyperglycemia Not
Controlled by Diet
and requiring Therapy
Physician review.
Decision to start Glyburide
Start Glyburide 2.5 mg q. a.m.
Follow up in One Week
Patient Experiencing Hypoglycemia
Yes
Consider decreasing oral
agent and change food plan
No
Blood Glucose Improving
as expected
Yes
Patients remains on oral
agent.
No
Increase Oral Agent
(Glyburide)
Recommended Dose Adjustments (mg)
Increase once weekly
Up to 6 week period
Start
a.m.
Next
a.m.
Next
am-pm
Next
am-pm
Max
am-pm
2.5 mg
5 mg
5mg/lOmg
lOmg/5mg
lOmg/lOmg
am = before breakfast
pm = bedtime
Pg. 23
Glucose control achieved?
Yes
No
Continue dose
Switch to insulin
Ultrasounds — Level II
Scope:
□ To perform Level II Targeted Ultrasounds for high-risk OB patients.
Appropriate patients for referral into include:
□ Rh disease
□ Fetal anomaly identified on a prior scan
□ Targeted anatomy scan for diseases and situations where there is a known risk of increased
incidence of fetal abnormalities (e.g. seizure disorder, Class B Diabetes, Congenital Heart
Disease)
□ Targeted anatomy scan for history of a prior infant with an abnormality
□ Abnormal TAST and only if they want Genetic Counseling
□ AMA (Advance Maternal Age) only if they want Genetic Counseling
□ Targeted scan for known twins
□ Growth scans for known twins
□ Suspected pelvic mass
□ Suspected uterine anomaly
Please do NOT refer the following patients to our clinic:
□ Level I (routine) Ultrasounds
□ Dating/Unsure of last menstrual period
□ Size greater/less than dates
□ Fetal Presentation
□ ACOG
□ Any completed USG results
Pg. 24
Page 1 of 6
GUIDELINES FOR DIABETES IN PREGNANCY
EFFECTIVE DATE 7/1/11
*This document does not define a standard of care, nor is it intended to dictate an exclusive
course of management. There are other accepted strategies for the management of diabetes in
pregnancy.
I.
Screening for gestational diabetes mellitus (GDM) (from Metzger BE, et al. Diabetes
Care 2010, 33:676-681)
A. Universal screening at 24-28 weeks
If pregestational diabetes is present by history, then screening is not necessary.
Management will be with insulin. Further assessment as described in Appendix A.
B. Selected screening early in pregnancy should be performed at the first prenatal visit.
1. Indications for select early screening:
a. History of gestational diabetes in a prior pregnancy
b. Previous macrosomic infant (>4000 gm)
c. Family history of diabetes in first degree relative
d. Obesity (BMI > 30)
e. Unexplained stillbirth in previous pregnancy
f. Maternal age at delivery to be > 35
2. Diagnostic Criteria for overt diabetes (to be measured on high risk women
described as above)
First prenatal visit
Measure AIC (this is the preferred method; others listed below)
To diagnose overt diabetes in pregnancy
Measure of glycemia
Consensus threshold
FPG‡
>7.0 mmol/l (126 mg/dl)
A1C‡
>6.5% (DCCT/UKPDS standardized)
Random plasma glucose
>11.1 mmol/l (200 mg/dl) + confirmation§
* ‡One of these must be met to identify the patient as having overt diabetes in pregnancy. §If a random
plasma glucose is the initial measure, the tentative diagnosis of overt diabetes in pregnancy should be
confirmed by FPG or A1C using DCCT/UKPDS-standardized assay
.
3. If overt diabetes is diagnosed, then treatment and follow-up as for preexisting
diabetes. Refer to High Risk OB (HROB).
4. If results are not diagnostic of overt diabetes and fasting plasma glucose >5.1 mmol/l
(92 mg/dl) but <7.0 mmol/l (126 mg/dl), then diagnose as GDM. Management as
described in section II and III of this document. It the fasting plasma glucose is <5.1
mmol/l (92 mg/dl), test for GDM from 24 to 28 weeks’ gestation with a 75-g OGTT
Revised 6/24/11
Page 2 of 6
C. If the early screen at first prenatal visit is negative (<5.1 mmol/1 or <92 mg/dl), then
repeat at 24-28 weeks. Screen with a 2hr 75gm oral glucose tolerance test (75gm
OGTT)
D. Screen with 75 gm oral glucose tolerance test:
1. Diagnostic Criteria:
1.
Positive screen when any one or more values is elevated
2. Method:
1.
At least 8 hours of fasting prior to 75gm glucose screen
2.
Fasting blood glucose followed by a 2 hour 75gm oral glucose
tolerance test
3.
Plasma glucose at 1, and 2 hours after ingestion of glucose
3. Diagnosis of gestational diabetes: at least one abnormal value:
Fasting>
92 mg/dl
1 hour >
180 mg/dl
2 hour >
153 mg/dl
4. Diagnosis of overt diabetes if fasting plasma glucose is > 126 mg/dl. Refer to
HROB. Management with insulin and further assessment as described in
Appendix A.
II.
Management
A. Refer to Diabetes Education (see Appendix B for summary of education)
B. Diet
1.
Arrange Nutritional counseling
2.
IDEAL body weight (IDBW): 5 ft= 100lb. + 5lb. for every inch
>5 ft.
3.
Caloric intake: 30K cal/kg/day if body weight is IDBW +/- 20%.
This may be adjusted by dietician depending on body weight.
4.
CHO, 40%; Protein,20%- 30%; fat, 20%-30%.
5.
3 Meals and 2- 3 snacks daily.
C. Glucose monitoring four times daily: Fasting and 2hr glucose after breakfast,
lunch and dinner
D. Issue Glucometer and give education. A glucose log must be kept by patients.
Check fasting glucose and 2 hours after main meals (2 hr pc); four times daily.
Record mean fasting and mean 2 hr pc values each visit in the progress note.
E. If the mean fasting glucose is greater than 92 mg/dl, or the mean 2 hour post
prandial glucose is greater than 120 mg/dl, refer the patient to the High Risk
Obstetrics clinic within one week.
Revised 6/24/11
Page 3 of 6
F. If the mean fasting glucose is greater than 120 mg/dl or if 2 hour glucose mean is
greater than 200 mg/dl then, this patient needs immediate evaluation. Consult
with the UMCB faculty at 512-450-3775.
III.
Therapy — women needing therapy other than diet should be referred to HROB.
A. Insulin (Humulin)
Initial calculation for total dose:
.8 units/kg/IBW daily — first trimester
.9 units/kg/IBW daily — second trimester
1.0 units/kg/IBW daily — third trimester
2/3 AM (3/4 NPH, ¼ Humalog) — @ breakfast
1/3 PM (1/2 NPH, ½ Humalog) — Humalog @ supper; NPH @ bedtime snack
B. Oral Agent Therapy — see Appendix C. In general this is reserved for gestational
diabetes only. Overt or preexisting diabetes should be managed with insulin in
almost all cases.
IV.
V.
Antenatal Testing
A. A1 diabetes
B. A2 diabetes (uncomplicated)
NST weekly at 32 weeks; twice weekly at 36 weeks
C. Pregestational or overt diabetes (uncomplicated)
Fetal movement chart at 28weeks
D. Diabetes complicated by hypertension, other evidence of vascular disease, renal
or eye involvement, or other significant medial or obstetric complications.
E. Other interventions and testing as indicated by clinical finding
Delivery
A. A1 diabetes at 41 weeks
B. Medically managed or insulin dependent diabetes 38.5 to 40 weeks depending on
control and patient reliability
C. Delivery prior to 38.5 week may require amniocentesis for pulmonary maturity,
unless an absolute indication for delivery based on maternal or fetal condition
exists. There is considerable controversy surrounding this issue.
Revised 6/24/11
Page 4 of 6
Appendix A
Early Assessment (< 20 weeks)
Overt or Pregestational Diabetes
MATERNAL
Physical Exam
Possible Tests
Recommendation
EKG
Retinal evaluation
T4, TSH 24 hr urine
Collection for Cr. Cl.
and total protein, and
urine culture
Ophthalmology Consult
Consult with appropriate
Medical or MFM consult if
required
Evaluate for:
HTN
Retinopathy
Goiter
Nephropathy
Obesity
Glucometer (test 4 times daily)
Glycemic Control
regarding obesity
Hb A1C
Diabetic Counseling
Dietician consult
FETAL
Gestational Age Assessment
Physical Exam
Early ultrasound if possible
Anatomic Assessment
Appropriate fetal screening MFM Consult in all cases
(1st or 2nd trimester
ultrasound for dating)
MS-AFP at 15 0/7
(even if they had a 1st
trimester screening) This is
valid through 20 0/7 weeks
Targeted ultrasound at
18 -22 weeks for anatomy
Fetal echocardiogram at 24 weeks
Revised 6/24/11
Page 5 of 6
Appendix B
CommUnityCare Diabetes and Pregnancy Clinic
Guidelines for Diabetes Education
1.
Patients new to the OB Diabetic Clinic are provided education on Mondays, in a class
setting. Education is provided in the client’s primary language. The template is for 3
classes of 4 patients each at 9am, 10:30 am and 12 noon. Patients are instructed on
importance of good control of blood sugar during pregnancy, as well as possible
complication with poor control. Patients are encouraged to walk for exercise, unless
medically prohibited. They are also instructed on exercise precautions. They are
instructed on use of the glucose log, timing of testing for fasting and 2 hours after meals,
and glucose logs. MAP patients are provided with a Contour Meter and instructed in its
use as well as in the use of the control solution. Documentation is recorded in NextGen.
2.
Patients are counseled on a 2000 calorie Gestational Diabetes meal plan of 3 meals and 3
snacks. Reference materials are provided for the meal plan, food safety, risk reduction of
Type 2 Diabetes (when applicable) and healthy food habits for infants and children. Food
models are used to demonstrate sample meals, snacks and food portion sizes and patients
are evaluated on their knowledge of foods high in carbohydrates. Patients are also
provided with a 1 week food log to record their intake and are asked to return it at their
next clinic visit. The dietitian will review the food log with the patient and provide
feedback. Documentation is recorded in NextGen.
3.
Tuesdays, the dietitian and nurse educator are available in the clinic to follow up on
patients taught the previous week in class, to teach patient needing Glyburide or insulin
and to see any patients referred by the physician. We like to follow up with any patients
who have been discharged from the hospital.
4.
Please order insulin dose in increments of 2. We try to teach all patients needing insulin
on the 1 cc insulin syringes which are marked only in 2’s, so even numbers of insulin can
confusing to our clients.
Thank you,
Bea Guerra, RN and Dahlia Gamez, RN, CDE
Revised 6/24/11
Page 6 of 6
Appendix C
Oral Agent Therapy for Gestational Diabetes (NEJM 2OOO: 343:1134-8)
Hyperglycemia Not
Controlled by Diet
and requiring Therapy
Physician review.
Decision to start Glyburide
Start Glyburide 2.5 mg q. a.m.
Follow up in One Week
Patient Experiencing Hypoglycemia
Yes
Consider decreasing or agent
And change food plan
No
Blood Glucose Improving
as expected
Yes
Patients remains on oral
agent.
No
Increase Oral Agent
(Glyburide)
Recommended Dose Adjustments (mg)
Increase once weekly
Up to 6 week period
Start
Next
Next
Next
Max
a.m.
a.m.
am-pm
am-pm
am-pm
2.5 mg
5 mg
5mg/1Omg 1Omg/5mg 1Omg/1Omg
Glucose control achieved?
Yes
No
Continue dose
Switch to insulin
am = before breakfast
pm = bedtime
Effective date 7/1/11
Revised 6/24/11

Medical Access Program Provider Handbook TABLE OF CONTENTS

Transcription

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