PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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Clinical Practice Guidelines Diagnosis and Management of Pediatric Asthma Medications – (cont.) Drug Class/Drug Name Strength & Dosage Form Usual Dosing Holding Chambers/PFMs Product Size Availability/Location (Brand®) Prednisone 1, 5, 10 & 20 mg tabs 5 mg/5 ml oral soln. 1-2 mg/kg/day for 3-5 days Adult Spacer Aerochamber® Large (> 4 yrs) Pharmacy Item – Write a Prescription Pediatric Spacer w/Face Mask Aerochamber® Medium Respiratory Therapy Order (1-4 yrs) Infant Spacer w/Face Mask Aerochamber® Small Respiratory Therapy Order (< 1 yr) Prednisone (Prelone®) 15 mg/5 ml syrup 1-2 mg/kg/day for 3-5 days Peak Flow Meter Asthma Check® Respiratory Therapy Order For all patients MDI/spacer has been dispensed, MDI/spacer education has been documented. Severity 2 Symptoms Night sxs Lung Function Level * if able Step 1: Mild intermittent Min follow-up 6 mos Step 2: Mild Persistent Min follow-up 3 mos Step 3: Moderate Persistent Min follow-up 2 mos Step 4: Severe Persistent Min follow-up 1 mo Acute Exacerbation • sxs ≤ 2xs/wk • no sxs; normal PEF between exacerbations • brief exacerbations (few hours – few days) • Sxs > 2xs/wk; < 1 x/day • Exacerbations may affect activity • Daily sxs • Daily use of shortacting ß2 agonist • Exacerbations affect activity • Exacerbations ≥ 2 xs/wk; may last days • Continual sxs • Limited physical activity • Frequent exacerbations ≤2 xs/mo Clinical Practice Guidelines Diagnosis and Management of Adult Asthma • FEV1 or PEF ≥ 80% predicted • PEF variability < 20% > 2 xs/mo • FEV1 or PEF ≥ 80% predicted • PEF variability 20- 30% > 1 x/wk • FEV1 or PEF > 60% < 80% predicted • PEF variability >30% Frequent • FEV1 or PEF ≤ 60% predicted • PEF variability • > 30% Adult Patients Peak flow meter readings should be done on all office visits as part of vital signs. Baseline spirometry is recommended for all patients. Quick Relief Education (see attached formulary guidelines) Long Term Control (see attached formulary guidelines). Note: All patients on long-term control must have quick relief medication None needed Daily medications: • Low dose inhaled corticosteroid (.eg., beclomethasone 4- 12 puffs/day OR • Leukotriene modifier (requires approval by Asthma Pharmacy Specialist (214-786-1738 or asthma clinic referral) Daily medications: • Med dose inhaled corticosteroid (e.g., fluticasone 110 mcg 2-6 puffs/day) OR • Low-med dose inhaled corticosteroid AND long acting brochodilator (salmeterol) and/or less preferable to salmeterol: leukotriene modifier, albuterol tabs, or theoplylline. The inhalled brochodilator combination is the preferred choice for nighttime sxs. Daily medications: • High dose inhaled corticosteroid (e.g., fluticasone 220 mcg > 3 puffs/day, restricted to asthma clinic AND • Long-acting inhaled ß2 agonists, and/or leukotriene modifier or theophylline or long-acting ß2 agonist tabs, AND, if needed • Corticosteroid tabs (2 mg/kg/day generally not to exceed 60 mg/day). Wean ASAP; if unable, specialist req’d. For acute exacerbation of usually well controlled asthmatics, steroid burst Short-acting bronchodilator: • Inhaled with spacer, nebulized, or oral ß2 agonists pm sxs (e.g., albuterol) Short-acting bronchodilator: • Inhaled ß2 agonists prn sxs (e.g. albuterol) Short-acting bronchodilator: • Inhaled ß2 agonists prn sxs (e.g. albuterol) Short-acting bronchodilator: • Inhaled spacer, nebulized, or oral ß2 agonists prn sxs (e.g. albuterol) • Basic asthma facts • MDI/spacer technique • Roles of meds • Self-management plan • Action plan for acute exacerbations and prophylaxis during viral illnesses • Environmental control; avoid trigger exposure Step 1, Plus: • Teach patient monitoring • Refer to group education if available • Review and update patient management plan Same as Step 2, Plus: • Consider Case Mgmt if exacerbations persist Same as Step 3, Plus: • Refer to individual education/counseling and support services for additional interventions These practice guidelines are based on medical literature and opinions that are current as of the date stated above and are not intended to replace your clinical medical judgment. Each medical decision should be based on current medical knowledge and practice considered in the clinical circumstances of the individual patient. Copyright© 2002 PHHS 131
Appendix D – Continued Clinical Practice Guidelines Diagnosis and Management of Adult Asthma Medications Drug Class/Drug Name (Brand®) Strength & Dosage Form Usual Dosing (per nostril) Quantity/ Container Day Comments/ Restrictions Supply NASAL SPRAYS Beclomethasone (Beconase AQ®) Aqueous 42 mcg/spray 1 spray q 12 hrs 200 sprays (25 gm) 25-50 Use 1 st Budesonide (Rhinocort®) Dry Powder 32 mcg/spray 1-2 sprays 1 12 hrs or 4 sprays qd 200 sprays (7 gm) 25-50 Alternative to aqueous sprays Fluticasone (Flonase®) Aqueous 50 mcg/spray 1-2 sprays q 24 hrs 120 sprays (16 gm) 30-60 Use 2 nd – Restricted to ENT, Allergy/Asthma, Pulmonary Ipratropium (Atrovent®) Aqueous 0.03% nasal spray (21 mcg/spray) 0.06% nasal spray (42 mcg/sp) 2 sprays q 8-12 hrs prn 2 sprays q 6-8 hrs prn 345 sprays (30 ml) 165 sprays (15 ml) Oxymetazoline (Afrin®) Aqueous 0.05% nasal spray or drops 1-2 sprays q 8-12 hrs prn X3 days 15 ml only Normal Saline (Ocean®, Ayr®) 0.9% nasal spray or drops 1-2 sprays prn 45 ml Drug Class/Drug Name (Brand®) Strength & Dosage Form Usual Dosing (per nostril) Quantity/ Container Day Supply SHORT-ACTING ß2 AGONIST Albuterol (Ventolin®, Proventil®) 90 mcg/puff, 2mg/5 ml syrup, 0.083% premix & 5 mg/ml meb. Solm. 2 puff q 4-6 hrs prn 200 puffs (17 gm) 25 amps.box 20 ml bottle 30-45 10-15 Indicated for treating rhinitis from the common cold Comments/ Restrictions 25 All patients need a short ß2 for acute sxs LONG-ACTING ß2 AGONIST Salmeterol (Serevent®) 21 mcg/puff 2 puffs q 12 hrs 120 puffs (13 gm) 30 Max-2 puffs bid. Patient must have short ß2 for acute sxs Albuterol (Proventil Repetabs®) 4 mg SR tabs ANTICHOLINERGIC Ipratropium (Atrovent®) 18 mcg/puff, 500 mcg/2/5 ml premix neb. soln. 2 puffs q 6 hrs 200 puffs (14 gm) 25 amps/box CROMOLYN/NEDOCROMIL Nedocromil (Tilade®) 1.75 mg/puff 2 puffs q 6 hrs 104 puffs (16.2 gm) 13 *MDI Auto Switch (Cromolyn 2 puffs qid to Nedocromil 3 puffs bid) May be dosed 3-4 puffs bid LEUKOTRIENE MODIFIERS Montelukast (Singulair®) 10 mg tabs (restricted) 10 mg qd (adult) 10 mg Restricted – Pulmonary, Allergy/Asthma (Requires approval by Asthma Pharmacy Specialist (214 786- 1738) or referral 25 Drug Class/Drug Name (Brand®) Strength Usual Dosing CORTICOSTEROID INHALERS Beclomethasone (Beclovent®) 42 mcg/puff 2-4 puffs q 6-12 hrs Fluticasone (Flovent 110®) 110 mcg/puff 2-4 puffs q 12 hrs Fluticasone (Flovent 220®) 220 mcg/puff 2-4 puffs q 12 hrs DAILY Comparative Dosage Quantity/ Container Low 4-12 puffs/day 200 puffs (17 gm) Low 2 puffs/day 120 puffs Medium 2-6 puffs/day (13 gm) High >6 puffs/day High > 3 puffs/day 120 puffs (13 gm) Day Supply Comments/Restrictions 15-100 Use for mild persistent asthma 60 Use for moderate persistent asthma 20-60
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Parkland KIDSfirst, Parkland CHIP P
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Notification of Change in Provider
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CLAIMS SUBMISSION .................
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Quick Reference Checklist This manu
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Plan specified services. However, c
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CHIP Covered Services PCHP provides
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• Surgical implants • Other art
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Outpatient Mental Health Services I
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• Out-of-network services not aut
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CHIP Perinatal Covered Services Cov
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15 Covered Benefit CHIP Perinate Ne
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Covered Benefit CHIP Perinate Newbo
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• Personal comfort items includin
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• Donor non-medical expenses •
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SUPPLIES COVERED EXCLUDED COMMENTS/
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SUPPLIES COVERED EXCLUDED COMMENTS/
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Coordination between Physical and B
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in the provision of care and servic
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statement indicating that members s
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As the Primary Care Provider you mu
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Other Access Standards Service Stan
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Members Right to Select Network Oph
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HMO/Provider Coordination PCHP will
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45 • describe the range of medica
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Coordination of Care The Primary Ca
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Coordination with Texas Department
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Presentation at Emergency Room afte
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If the complaint is received verbal
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Expedited Appeal can be made verbal
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CHIP Eligibility CHIP KidsFirst Mem
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• Information concerning the grie
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Parkland Community Health Plan Memb
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Pregnant Teens Please call Parkland
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your income. Co-payments do not app
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Member’s Right to Designate an OB
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70 To report providers use this add
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5. Network providers must report an
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To request to be a Specialist servi
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• OB/Gyn • Periodic Health Chec
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The table below provides HHSC Manag
Page 87 and 88: CHIP Cost Sharing Caps Members rece
Page 89 and 90: of these two dates: July 18, 2007,
Page 91 and 92: (DD) Diagnosis code by specific ser
Page 93 and 94: (PP) Attending physician ID (UB-04,
Page 95 and 96: (2) post-partum visits within 60 da
Page 97 and 98: CHIP Member Enrollment and Disenrol
Page 99 and 100: • In order to synchronize all CHI
Page 101 and 102: Provider Participation Requirements
Page 103 and 104: • Evidence of state licensure, an
Page 105 and 106: U1 U2 U3 Medically necessary delive
Page 107 and 108: PROCEDURE DESCRIPTION PROCEDURE COD
Page 109 and 110: provider actually treating the memb
Page 111 and 112: themselves appropriately and follow
Page 113 and 114: Medical Record Standards The medica
Page 115 and 116: 1. History and Physical Examination
Page 117 and 118: WIC services include providing nutr
Page 119 and 120: As soon as the member knows they wi
Page 121 and 122: 3) by the director to the employee
Page 123 and 124: In addition to the previously state
Page 125 and 126: Prior Authorization The CHIP Perina
Page 127 and 128: Appendix A Universal Referral/Prior
Page 129 and 130: Appendix B Consent for Disclosure 1
Page 131 and 132: PERMISSION TO RELEASE CONFIDENTIAL
Page 133 and 134: EXAMPLE FORM PRIVATE PAY AGREEMENT
Page 135 and 136: Appendix D Clinical Practice Guidel
Page 137: Appendix D - Continued Clinical Pra
Page 141 and 142: RATIONALE: Attention-Deficit/ Hyper
Page 143 and 144: Appendix G Urinary Tract Infections
Page 145 and 146: Follow-up • Follow-up urine cultu
Page 147 and 148: RATIONALE: Prevention of RSV Illnes
Page 149 and 150: RATIONALE: Treatment of Group A Str
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PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

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