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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage17DateAugust 1, 2013DrugIbuprofen suspension 100 mg/5 mlIbuprofen tablets, 200 mgLoperamide HCl liquid, 1 mg/5 mlLoperamide HCl tablets, 2 mgLoratadine tablets, 10 mgLoratadine syrup, 5 mg/5 mlMagnesium hydroxide suspension, 400 mg/5 mlMeclizine hydrochloride tablets, 12.5 mgMeclizine hydrochloride tablets, 25 mgMeclizine hydrochloride chewable tablets, 25 mgMiconazole nitrate cream, 2% topicalMiconazole nitrate cream, 2% vaginalMiconazole nitrate vaginal suppositories, 100 mgNeomycin-bacitracin-polymyxin ointmentNicoderm transdermal patch, 7 mg/24 hrNicotine transdermal patch, 7 mg/24 hrNicoderm transdermal patch, 14 mg/24 hrNicotine transdermal patch, 14 mg/24 hrNicoderm transdermal patch, 21 mg/24 hrNicotine transdermal patch, 21 mg/24 hrNicorette gum, 2 mgNicotine gum, 2 mgNicorette gum, 4 mgNicotine gum, 4 mgCommit lozenge, 2 mgNicotine polacrilex lozenge, 2 mgCommit lozenge, 4 mgNicotine polacrilex lozenge, 4 mgPermethrin lotion, 1%√ = PriorAuthorizationRequiredPolyethylene glycol 3350 powder 119 grams √ for ages 13-18Polyethylene glycol 3350 powder 238 grams √ for ages 13-18Polyethylene glycol 3350 powder 510 grams √ for ages 13-18Pseudoephedrine syrup, 30 mg/5 mlPseudoephedrine tablets, 30 mgPseudoephedrine tablets, 60 mgPyrethrins-piperonyl butoxide liquid, 0.33-4%Pyrethrins-piperonyl butoxide shampoo, 0.3-3%Pyrethrins-piperonyl butoxide shampoo, 0.33-4%Salicylic acid liquid 17%Sennosides-docusate sodium tablets, 8.6-50 mgSennosides syrup, 8.8 mg/5 mlSennosides tablets, 8.6 mg√√√√√√√√√√√√√√
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage18DateAugust 1, 2013Drug√ = PriorAuthorizationRequiredSenna tablets, 187 mgSodium chloride hypertonic ophthalmic ointment, 5%Sodium chloride hypertonic ophthalmic solution, 5%Tolnaftate 1% creamTolnaftate 1% powderTolnaftate 1% solutionNonprescription multiple vitamins and minerals may also be payable underconditions specified under PRIOR AUTHORIZATION REQUIREMENTS.Oral solid forms of these items shall be prescribed and dispensed in aminimum quantity of 100 units per prescription, except when dispensed via aunit-dose system.8. Medical SuppliesPharmacies that dispense medical equipment and supplies should follow theMEDICAL EQUIPMENT AND SUPPLY DEALER PROVIDER MANUAL and purchasea supply of CMS-1500 claim forms from any supplier.C. PRIOR AUTHORIZATION REQUIREMENTSPrior approval is required for the following:♦ ADD/ADHD/narcolepsy agents♦ Alpha 2 agonists, extended release♦ Alpha 1 -proteinase inhibitor enzymes♦ Amylino mimetic (Symlin ® )♦ Angiotensin receptor blockers♦ Anti-acne♦ Antiemetic-5HT3 receptor antagonists/substance P neurokinin products♦ Antifungal♦ Antihistamines♦ Anti-thrombotics (injectable)♦ Becaplermin (Regranex ® )♦ Benzodiazepines♦ Biologicals for ankylosing spondylitis♦ Biologicals for arthritis♦ Biologicals for inflammatory bowel disease♦ Biologicals for plaque psoriasis
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