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

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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.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage32DateAugust 1, 201315. BenzodiazepinesPrior authorization is required for nonpreferred benzodiazepines. Payment fornonpreferred benzodiazepines will be authorized in cases with documentationof previous trial and therapy failure with two preferred products. Requestsfor clobazam (Onfi) will be considered for a diagnosis of seizures associatedwith Lennox-Gastaut syndrome (LGS) in patients two years of age and olderwhen used as an adjunctive treatment. If a long-acting medication isrequested, one of the therapeutic trials must include the immediate-releaseform of the requested benzodiazepine.Prior authorization will be approved for up to 12 months for documented:♦ Generalized anxiety disorder♦ Panic attack with or without agoraphobia♦ Seizure♦ Nonprogressive motor disorder♦ DystoniaPrior authorization requests will be approved for up to a three-month periodfor all other diagnoses related to the use of benzodiazepines.The required trials may be overridden when documented evidence is providedthat use of these agents would be medically contraindicated.Use form 470-4117, Request for Prior Authorization: Benzodiazepines, torequest prior authorization. Click here to see a sample of the form.16. Biologicals for Ankylosing SpondylitisPrior authorization is required for biologicals used for ankylosing spondylitis.Payment will be considered following inadequate responses to two preferrednon-steroidal anti-inflammatories (NSAIDs) at maximum therapeutic dosesunless there are documented adverse responses or contraindications toNSAID use. Trials should be at least three months in duration.Patients with symptoms of peripheral arthritis must also have failed a 30-daytrial with at least one conventional disease-modifying antirheumatic drug(DMARD), unless there is a documented adverse response or contraindicationto DMARD use. DMARDs include sulfasalazine and methotrexate.
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