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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage25DateAugust 1, 20134. ADD/ADHD/Narcolepsy AgentsPrior authorization (PA) is required for ADD/ADHD/narcolepsy agents forpatients 21 years of age or older under the following conditions:♦ Attention deficit disorder (ADD) or attention deficit hyperactivity disorder(ADHD) meeting the DSM-IV criteria confirmed by a standardized ratingscale (such as Conners, Vanderbilt, Brown, Snap-IV). Symptoms musthave been present before 12 years of age and there must be clearevidence of clinically significant impairment in two ore more environments(social, academic, or occupational).♦ Narcolepsy with diagnosis confirmed with a recent sleep study (ESS,MSLT, PSG).♦ Excessive sleepiness from obstructive sleep apnea/hypopnea syndrome(OSAHS) with documentation of non-pharmacological therapies tried(weight loss, position therapy, CPAP at maximum titration, BiPAP atmaximum titration, or surgery) and results from a recent sleep study(ESS, MSLT, PSG) with the diagnosis confirmed by a sleep specialist.Payment for a nonpreferred agent will be authorized only for cases in whichthere is documentation of previous trial and therapy failure with a preferredagent.If a nonpreferred long-acting medication is requested, a trial of thepreferred immediate-release and extended release product of the samechemical entity is required.The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Use form 470-4116, Request for Prior Authorization: ADD/ADHD/NarcolepsyAgents, to request prior authorization. Click here to see a sample of theform.