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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage30DateAugust 1, 201311. Antifungal TherapyPrior authorization is not required for preferred oral antifungal therapy for acumulative 90 days of therapy per 12-month period per patient.Payment for any oral antifungal therapy beyond this limit will be authorized incases where the patient has a diagnosis of an immunocompromised conditionor a systemic fungal infection. This prior authorization requirement does notapply to nystatin.Prior authorization is required for all nonpreferred oral antifungal therapybeginning the first day of therapy. Payment for a nonpreferred oralantifungal agent will be authorized only for cases with documentation ofprevious trial and therapy failure with a preferred agent.Use form 470-4094, Request for Prior Authorization: Antifungal Drugs, torequest prior authorization. Click here to see a sample of the form.12. AntihistaminesPrior authorization is required for all nonpreferred antihistamines andpreferred second-generation prescription antihistamines.♦ Members aged 21 or older must have three unsuccessful trials with oralantihistamines that do not require prior authorization prior to the approvalof a nonpreferred oral antihistamine. Two of the trials must be withcetirizine and loratadine.♦ Members aged 20 or younger must have unsuccessful trials of cetirizineand loratadine prior to the approval of a nonpreferred oral antihistamine.The required trials may be overridden when documentation is provided thatthe use of these agents would be medically contraindicated.Use form 470-4095, Request for Prior Authorization: Antihistamines, torequest prior authorization. Click here to see a sample of the form.