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Drugs requiring transmission of a diagnosis code

Revised August 2016

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

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

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

Medication and covered diagnosis

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