Prescribed Drugs Provider Manual - Iowa Department of Human ...

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage113DateAugust 1, 2013a. Age EditsCertain medications are payable only for specific age groups:Drug Name/ClassDrugs FDA indicated forthe treatment ofAlzheimer’s dementia(donepezil, galantamine,memantine, andrivastigmine)Aldara (imiquimod)Asmanex 110 mcgBrovanaAge EditPayable for members40 years of age andolderPayable for members12 years of age andolderPayable for membersless than 12 years ofage.Payable for members18 years of age andolder.Prior Authorization(PA) RequirementPA is required formembers under 40years of age.PA is required formembers under 12years of age.PA is required formembers 12 years ofage and older.PA is required formembers under 18years of age.Clorazepate Payable for members 9years of age and older.PA is required formembers under 9years of age.CompleraDuleraEdurantEligardErivedgePayable for members18 years of age andolder.Payable for members12 years of age andolder.Payable for members18 years of age andolder.Payable for members18 years of age andolder.Payable for members18 years of age andolder.PA is required formembers under 18years of age.PA is required formembers under 12years of age.PA is required formembers under 18years of age.PA is required formembers under 18years of age.PA is required formembers under 18years of age.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage114DateAugust 1, 2013Drug Name/ClassFemara (letrozole)FlurazepamAge EditPayable for members50 years of age andolder.Payable for members15 years of age andolder.Prior Authorization(PA) RequirementPA is required formember under 50years of age.PA is required formembers under 15years of age.Foradil Payable for members 5years of age and older.PA is required formembers under 5years of age.InlytaIsentress 25 mg and100 mg chewabletabletsJakafiNuvigil (armodafinil)OTC Polyethylene glycol3350 powderPayable for members18 years of age andolder.Payable for membersless than 12 years ofage.Payable for members18 years of age andolder.Payable with a PA formembers 17 years ofage and olderPayable for members 0to 12 years of age. PArequired for members13 to 18 years of age.Not covered formembers 19 years ofage or over.PA is required formembers under 18years of age.PA is required formembers 12 years ofage and older.PA is required formembers under 18years of age.PA is required formembers under 17years of age.PA is required formembers 13-18 yearsof age.Oxazepam Payable for members 6years of age and older.PA is required formembers under 6years of age.PerforomistProvigil (modafinil)Payable for members18 years of age andolder.Payable for members16 years of age andolderPA is required formembers under 18years of age.PA is required formembers under 16years of age and 21years of age andolder
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