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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage115DateAugust 1, 2013Drug Name/ClassRevlimidAge EditPayable for members18 years of age andolder.Prior Authorization(PA) RequirementPA is required formembers under 18years of age.Serevent Payable for members 4years of age and older.PA is required formembers under 4years of age.Singulair 4 mg granulesStribildVeregen (sinecatechins)Zytigab. Cost Effectiveness EditPayable for membersless than 2 years ofagePayable for members18 years of age andolder.Payable for members18 years of age andolder.Payable for members18 years of age andolder.PA is required formembers 2 years ofage and older.PA is required formembers under 18years of age.PA is required formembers under 18years of age.PA is required formembers under 18years of age.Drug Dosage AlternativeAntivert tablet 50 mg Deny. Use two meclizine HC1 25 mgtablets.Benzonatate capsule 200 mg Deny. Use two benzonatate 100 mgcapsules.Buspirone tablet 30 mg Deny. Use two buspirone 15 mgtablets.Clindamycin capsule 300 mg Deny. Use multiples of clindamycin150 mg capsule.Hydroxyzine HC1tabletsHydroxyzine pamoatecapsulesImipramine pamoatecapsulesProzac or fluoxetineHC1 capsulesRheumatrex25 & 50mgDeny. Use hydroxyzine pamoate 25& 50 mg capsules.100 mg Deny. Use hydroxyzine pamoate 50mg capsules.Deny. Use imipramine HCL tablets.40 mg Deny. Use two fluoxetine HC1 20 mgcapsules.Deny. Use methotrexate.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage116DateAugust 1, 2013c. Dosage Form EditsForm Drug Dosage AlternativeProzac tablets fluoxetine 20 mg Deny. Use the capsule dosageform.Norvir tablets ritonavir 100 mg Deny. Use the capsule dosageform.Zantac capsules ranitidine 150 mg Deny. Use the tablet dosageform.Zantac capsules ranitidine 300 mg Deny. Use the tablet dosageform.d. Excessive Days SupplyThe claim will be rejected if the supply submitted is more than 31 days.If there is a valid reason why a supply of more than 31 days is required,request an exception to policy.e. High-Dollar ClaimsAll claims in excess of $10,000 submitted through the pharmacy point ofsale system will be rejected with a denial message stating, “Claimexceeds $10,000, please call POS Help Desk at 877-463-7671 or(515) 256-4608 locally.”After verifying that the quantity and days' supply on the claim arecorrect, contact the Pharmacy POS Help Desk for consideration of anoverride. A technician or pharmacist will review the informationsubmitted and determine if an override shall be issued.As a part of this process, the Iowa Medicaid Program Integrity Unit mayrequest additional medical documentation regarding the case from theprescriber or pharmacy. This policy is intended to help ensure thatproper billing procedures are being followed.
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