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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage27DateAugust 1, 20137. Amylino Mimetic (Symlin ® )Prior authorization is required for amylino mimetics (Symlin ® ). Payment willbe considered under the following conditions:♦ Diagnosis of Type 1 or Type 2 diabetes mellitus,♦ Concurrent use of insulin therapy,♦ Documentation of blood glucose monitoring three or more times daily,♦ Inadequate reduction in HbgA1C despite multiple titration with basal/bolusinsulin-dosing regiments.Initial authorizations will be approved for six months. Additional priorauthorizations will be considered on an individual basis after review ofmedical necessity and documented improvement in HbgA1C since thebeginning of the initial prior authorization period.Use form 470-4406, Request for Prior Authorization: Amylino Mimetic(Symlin ® ), to request prior authorization. Click here to see a sample of theform.8. Angiotensin Receptor Blocker (ARB)Payment for ARB and ARB combinations will be considered only for cases inwhich there is a contraindication or therapy failure with at least one ACE-I orACE-I combination.A completed prior authorization form will need to be submitted if:♦ A trial with an ACE-I or ACE-I combination of at least 30 days in length isnot found in the point-of-sale system, or♦ Evidence is provided that use of an ACE-I or ACE-I combination would bemedically contraindicated.Prior authorization is required for all nonpreferred ARBs and ARBcombinations beginning the first day of therapy.Payment for nonpreferred ARB or ARB combinations will be consideredfollowing documentation of recent trials and therapy failures with a preferredACE-I or ACE-I combination and a preferred ARB or ARB combination.Use form 470-4593, Request for Prior Authorization: Angiotensin ReceptorBlocker Before ACE Inhibitor, to request prior authorization. Click here to seea sample of the form.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage28DateAugust 1, 20139. Anti-Acne ProductsPrior authorization is required for all prescription topical acne products.Payment for the treatment of mild to moderate acne vulgaris will beconsidered under the following conditions:♦ The patient has has had previous trial and therapy failure with a preferredover-the-counter benzoyl peroxide product (covered without priorauthorization).♦ Requests for nonpreferred topical acne products will be authorized only forcases in which there is documentation of previous trials and therapyfailures with two preferred topical agents of a different chemical entity.♦ Requests for nonpreferred combination products will be considered onlyafter documented separate trials and therapy failures with the individualingredients.♦ The required trials may be overridden when documented evidence isprovided that the use of these agents would be medically contraindicated.♦ Form 470-4093, Request for Prior Authorization: Anti-Acne Products -Topical, is submitted to request prior authorization. Click here to see asample of the form.If the patient presents with a preponderance of comedonal acne, topicalretinoid products may be used as first-line agents with prior authorization.See Topical Retinoids for conditions specific to retinoid products.10. Antiemetic-5HT3 Receptor Antagonists/Substance P NeurokininProductsPrior authorization is required for preferred antiemetic-5HT3 receptorantagonists/substance P neurokinin medications for quantities exceeding thefollowing dosage limits per month.♦ Aprepitant/Emend ® :• Four 125 mg capsules• Eight 80 mg capsules♦ Dolasetron/Anzemet ® :• Five 50 mg tablets• Five 100 mg tablets
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