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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage31DateAugust 1, 201313. Anti-ThromboticsPrior authorization will be required for all nonpreferred injectable antithromboticagents beginning the first day of therapy. Payment fornonpreferred anti-thrombotic injectable agents will be authorized only forcases in which there is documentation of previous trial and therapy failurewith a preferred agent.Prior authorization is required for use of any preferred injectable antithromboticagent longer than 10 consecutive days. Payment for usage ofinjectable anti-thrombotic agents beyond this limit will be authorized forcases in which there is a clinical diagnosis of:♦ Pregnancy or planned pregnancy♦ Cancer-associated thromboembolic disease♦ History of thrombotic event while on anticoagulant therapy♦ Anti-thrombin III deficiency♦ Total hip arthroplasty♦ Warfarin allergyUse form 470-4096, Request for Prior Authorization: Anti-ThromboticInjectables, to request prior authorization. Click here to see a sample of theform.14. Becaplermin (Regranex ® )Prior authorization is required for Regranex ® . Payment for new prescriptionswill be authorized for ten weeks for patients who meet the following criteria:♦ Diagnosis of lower extremity diabetic neuropathic ulcers that extend intothe subcutaneous tissue or beyond.♦ Inadequate response to two weeks of wound debridement and topicalmoist wound dressing.Authorization will be approved beyond ten weeks for patients whose woundhas decreased in size by 30% after ten weeks.Use form 470-4276, Request for Prior Authorization: Becaplermin(Regranex ® ), to request prior authorization. Click here to see a sample ofthe form.