HUSKY Therapeutic Class ICD-10 Diagnosis List

Therapeutic Class Diagnosis Description Diagnosis Code Adrenergics, Aromatics, Schizoaffective disorder, depressive type F25.1 Non-Catecholamine and Major depressive disorder, single episode, mild F32.0 - F321.8 Central Nervous System Other specified depressive episodes F32.89 Stimulants Dysthymic disorder F34.1 Binge eating disorder F50.81 Primary hypersomnia F51.11 Insufficient sleep syndrome F51.12 Other hypersomnia not due to a substance or known physiological condition F51.19 Adjustment disorder with depressed mood F43.21 Other reactions to severe stress F43.8 Attention-deficit hyperactivity disorder F90.0 - F90.9 Hypersomnia, unspecified G47.10 * Diagnosis applicable to Llsdexamfetamine Idiopathic hypersomnia with long sleep time G47.11 Dimesylate only and Medical Necessity PA is Idiopathic hypersomnia without long sleep time G47.12 required Chronic fatigue, unspecified R53.82 * Polyphagia R63.2 For Provigil and Nuvigil ** Other specified depressive episodes F32.89 ** Sleep apnea, unspecified G47.30 ** Obstructive sleep apnea (adult) (pediatric) G47.33 ** denotes diagnoses exclusive to Provigil and ** Narcolepsy with cataplexy G47.411 Nuvigil. Submission with any other CNS agent will ** Narcolepsy without cataplexy G47.419 result in a claim denial ** Narcolepsy in conditions classified elsewhere with cataplexy G47.421 ** Narcolepsy in conditions classified elsewhere without cataplexy G47.429 ** Postviral fatigue syndrome G93.3 ** Neoplastic (malignant) related fatigue R53.0 ** Chronic fatigue, unspecified R53.82 Dermatologic Agents (Vitamin A Acne Derivatives/ Sarecycline) - Adapalene Molluscum contagiosum B08.1 Differin Acne vulgaris L70.0 Epiduo Acne conglobata L70.1 - Tretinoin Acne varioliformis L70.2 - Sarecycline HCL, oral Acne tropica L70.3 - Tazarotene Infantile acne L70.4 - Trifarotene Acne excoriee L70.5 Other acne L70.8 Acne, unspecified L70.9 Acne keloid L73.0 * Acanthosis nigricans L83 For Sarecycline HCL, Tazarotene, Tretinoin, and Epidermolysis bullosa Trifarotene * Epidermolysis bullosa simplex Q81.0 * denotes diagnoses exclusive to Sarecycline HCL, * Epidermolysis bullosa letalis Q81.1 Tazarotene, Tretinoin, and Trifarotene. * Epidermolysis bullosa dystrophica Q81.2 Submission with Adapalene NDCs will result in a * Other epidermolysis bullosa Q81.8 claim denial * Epidermolysis bullosa, unspecified Q81.9 * Other specified congenital malformations of skin Q82.8 * Congenital malformation of skin, unspecified Q82.9 Epoetin Alpha Refractory anemia - Procrit Refractory anemia without ring sideroblasts, so stated D46.0 - Epogen Refractory anemia with ring sideroblasts D46.1 Epoetin Alfa-epbx Refractory anemia with excess of blasts, unspecified D46.20 - Retacrit Refractory anemia with excess of blasts 1 D46.21 Epoetin Beta Refractory anemia with excess of blasts 2 D46.22 - Mircera Refractory anemia, unspecified D46.4 Darbepoetin Alpha Myelodysplastic syndrome, unspecified D46.9 - Aranesp Refractory cytopenia with multilineage dysplasia D46.A Refract cytopenia w multilin dysplasia and ring sideroblasts D46.B Myelodysplastic syndrome w isolated del(5q) chromsoml abnlt D46.C Other myelodysplastic syndromes D46.Z Vitamin B12 defic anemia Vitamin B12 defic anemia due to intrinsic factor deficiency D51.0 Vit B12 defic anemia d/t slctv vit B12 malabsorp w protein D51.1 Transcobalamin II deficiency D51.2 Other dietary vitamin B12 deficiency anemia D51.3 Other vitamin B12 deficiency anemias D51.8 Vitamin B12 deficiency anemia, unspecified D51.9 Dietary folate deficiency Dietary folate deficiency D52.0 Drug-induced folate deficiency anemia D52.1 Other folate deficiency anemias D52.8 Folate deficiency anemia, unspecified D52.9 Protein deficiency anemia Protein deficiency anemia D53.0 Other megaloblastic anemias, not elsewhere classified D53.1 Scorbutic anemia D53.2

Updated 5/2021 Current Provider Manual DX List HUSKY Therapeutic Class ICD-10 Diagnosis List

Other specified nutritional anemias D53.8 Nutritional anemia, unspecified D53.9 Drug-induced autoimmune hemolytic anemia Drug-induced autoimmune hemolytic anemia D59.0 Other autoimmune hemolytic anemias D59.1 Drug-induced nonautoimmune hemolytic anemia D59.2 Hemolytic-uremic syndrome D59.3 Other nonautoimmune hemolytic anemias D59.4 Paroxysmal nocturnal hemoglobinuria [Marchiafava-Micheli] D59.5 Hemoglobinuria due to hemolysis from other external causes D59.6 Other acquired hemolytic anemias D59.8 Acquired hemolytic anemia, unspecified D59.9 Familial dysautonomia [Riley-Day] G90.1 Pancytopenia Antineoplastic chemotherapy induced pancytopenia D61.810 Other drug-induced pancytopenia D61.811 Other pancytopenia D61.818 Chronic kidney disease, Chronic kidney disease, stage 1 N18.1 Chronic kidney disease, stage 2 (mild) N18.2 Chronic kidney disease, stage 3 ( moderate) N18.3 Subject to Medicare B cost avoidance for dually * Chronic kidney disease, stage 4 (severe) N18.4 eligible clients for specific diagnosis * Chronic kidney disease, stage 5 N18.5 * Claims with these diagnoses must be submitted * End stage renal disease (ESRD) N18.6 to Medicare B if the dual eligible client does not Chronic kidney disease, unspecified N18.9 reside in a SNF/NF. ABO isoimmunization of newborn P55.1 Encounter for aftercare following kidney transplant Z48.22 Procedure and treatment not carried out because of patient's decision for reasons of belief and group pressure Z53.1 Kidney transplant status Z94.0 Fat Absorption Decreasing Agents Other specified disorders of amino-acid metabolism - Xenical Disorders of gamma aminobutyric acid metabolism E72.81 Other specified disorders of amino-acid metabolism E72.89 Disorders of lipoprotein metabolism and other lipidemias Pure hypercholesterolemia Pure hypercholesterolemia, unspecified E78.00 Pure hyperglyceridemia E78.1 Mixed hyperlipidemia E78.2 Hyperchylomicronemia E78.3 Other hyperlipidemia Elevated Lipoprotein(a) E78.41 Other hyperlipidemia E78.49 Hyperlipidemia, unspecified E78.5 Lipoprotein deficiency E78.6 Lipodystrophy, not elsewhere classified E88.1 Fertility Stimulating Peparations,Non-FSH- Malignant neoplasm of prostate C61 - Clomiphene Citrate Testicular hypofunction E29.1 SILDENAFIL Primary pulmonary hypertension I27.0 - Revatio, Viagra Other secondary pulmonary hypertension Pulmonary hypertension unspecified I27.20 TADALAFIL Secondary pulmonary arterial hypertension I27.21 - Adcirca, Cialis Pulmonary hypertension due to left heart disease I27.22 Pulmonary hypertension due to lung diseases and hypoxia I27.23 Chronic thromboembolic pulmonary hypertension I27.24 Other secondary pulmonary hypertension I27.29 Raynaud's syndrome without gangrene I73.00 Raynaud's syndrome with gangrene I73.01 Idiopathic pulmonary fibrosis J84.112 Hereditary lymphedema Q82.0 Dyskinesia of esophagus K22.4 Unspecified effects of high altitude, initial encounter T70.20XA Unspecified effects of high altitude, subsequent encounter T70.20XD Unspecified effects of high altitude, sequela T70.20XS Other effects of high altitude, initial encounter T70.29XA Other effects of high altitude, subsequent encounter T70.29XD *FOR TADALAFIL ONLY Other effects of high altitude, sequela T70.29XS Please note: The quantity max is restricted to 90 * Enlarged prostate without lower urinary tract symptoms N40.0 units per fill when submitted with any of these * Enlarged prostate with lower urinary tract symptoms N40.1 (*) diagnoses * Nodular prostate without lower urinary tract symptoms N40.2 * Nodular prostate with lower urinary tract symptoms N40.3 INFUVITE ADULT 3,300 unit-200 unit- VIAL Link to Diagnosis list

Updated 5/2021 Current Provider Manual DX List