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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage19DateAugust 1, 2013♦ Buprenorphine (Butrans ) transdermal system♦ Buprenorphine/Naloxone (Suboxone ® )♦ Chronic pain syndrome agents♦ Colchicine (Colcrys ® )♦ Concurrent IM/PO antipsychotic use♦ Crizotinib (Xalkori ® )♦ Dalfampridine (Ampyra)♦ Dextromethorphan and Quinidine (Nuedexta)♦ Digestive enzymes♦ Dipeptidyl peptidase-4 (DPP-4) inhibitors♦ Dornase alfa (Pulmozyme ® )♦ Eplerenone (Inspra ® )♦ Erythropoiesis stimulating agents♦ Extended release formulations♦ Febuxostat (Uloric ® )♦ Fentanyl, short-acting oral products♦ Fingolimod (Gilenya)♦ Granulocyte colony stimulating factor agents♦ Growth hormones♦ Hepatitis C Protease Inhibitors-Oral♦ Immunomodulators, topical♦ Incretin mimetic♦ Insulin, pre-filled pens♦ Isotretinoin (oral)♦ Ivacaftor (Kalydeco)♦ Ketorolac tromethamine (Toradol ® )♦ Lidocaine patch (Lidoderm ® )♦ Linezolid (Zyvox ® )♦ Mifepristone (Korlym ® )♦ Modified formulations♦ Muscle relaxants♦ Narcotic agonist-antagonist nasal sprays♦ Nebivolol (Bystolic ® )♦ Nicotine replacement products♦ Nonparenteral vasopressin derivatives of posterior pituitary hormone products♦ Nonpreferred drugs♦ Nonsteroidal anti-inflammatory drugs♦ Omalizumab (Xolair ® )
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage20DateAugust 1, 2013♦ Oxycodone CR/ER (OxyContin ® )♦ Palivizumab (Synagis ® )♦ Proton pump inhibitors♦ Pulmonary arterial hypertension agents♦ Quantity limit override♦ Roflumilast (Daliresp)♦ Sedative/hypnotics-non-benzodiazepine♦ Selected brand name drugs♦ Serotonin 5-HT1 receptor agonists♦ Short-acting narcotics♦ Smoking cessation therapy (oral)♦ Sodium ozybate (Xyrem ® )♦ Thrombopoietin receptor agonists♦ Topical Retinoids for Acne♦ Vemurafenib (Zelboraf)♦ Vilazodone (Viibryd)♦ Vitamins, minerals and multiple vitamins♦ Vusion ointmentThe prescriber requests prior authorizations, not the pharmacy. The process is aprescriber fax-only system using the forms provided by the Iowa MedicaidEnterprise. The prescriber must request prior authorization by faxing thedesignated Request for Prior Authorization form to 800-574-2515.The specific criteria for approval of a prior authorization request are defined in thesubsections that follow. The prior authorization criteria are also available in chartformat on the web site www.iowamedicaidpdl.com.Requests require the information on the applicable Request for Prior Authorizationform, as noted in each subsection. Prior authorization forms may be obtained:♦ From the web site https://www.iowamedicaidpdl.com/pa_forms or♦ By calling the drug prior authorization help desk at (515) 256-4607 (local calls)or 877-776-1567. (Requests for prior authorizations will not be taken at thisnumber.)The IME Drug Prior Authorization Unit will consider other conditions as listed in thecompendia on an individual basis after reviewing documentation submittedregarding the medical necessity.
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