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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage33DateAugust 1, 2013Payment for nonpreferred biologicals for ankylosing spondylitis will beconsidered only for cases in which there is documentation of a previous trialsand therapy failures with two preferred biological agents.Use form 470-4521, Request for Prior Authorization: Biologicals forAnkylosing Spondylitis, to request prior authorization. Click here to see asample of the form.17. Biologicals for ArthritisPrior authorization is required for biologicals used for arthritis. Patientsinitiating therapy with a biological agent must:♦ Be screened for hepatitis B and C. Patients with active hepatitis B will notbe considered for coverage.♦ Not have been treated for solid malignancies, nonmelanoma skin cancer,or lymphoproliferative malignancy within the last five years of starting orresuming treatment with a biological agent.♦ Not have a diagnosis of congestive heart failure (CHF) that is New YorkHeart Association (NYHA) class lll or lV with an ejection fraction of 50% orless.♦ Be screened for latent TB infection. Patients with latent TB infection willonly be considered after one month of TB treatment. Patients with activeTB will only be considered upon completion of TB treatment.Payment will be considered under the following conditions:♦ A diagnosis of rheumatoid arthritis (RA). A trial and inadequate responseto two preferred disease-modifying antirheumatic drugs (DMARD) usedconcurrently. The combination must include methotrexate plus anotherpreferred oral DMARD (hydroxychloroquine, sulfasalazine, leflunomide, orminocycline). Upon an unsuccessful methotrexate trial in patients withestablished RA, the combination trial with a second DMARD may beoverridden if there is evidence of severe disease documented byradiographic erosions.♦ A diagnosis of moderate to severe psoriatic arthritis. A trial andinadequate response to the preferred oral DMARD, methotrexate(leflunomide or sulfasalazine may be used if methotrexate iscontraindicated).