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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage34DateAugust 1, 2013♦ A diagnosis of moderate to severe juvenile idiopathic arthritis. A trial andinadequate response to intraarticular glucocorticoid injections and thepreferred oral DMARD, methotrexate (leflunomide or sulfasalazine may beused if methotrexate is contraindicated).The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Payment for nonpreferred biologicals for arthritis will be considered only forcases in which there is documentation of a previous trials and therapy failureswith two preferred biological agents.Use form 470-4522, Request for Prior Authorization: Biologicals for Arthritis,to request prior authorization. Click here to see a sample of the form.18. Biologicals for Inflammatory Bowel DiseasePrior authorization is required for biologicals used for inflammatory boweldisease.Payment for nonpreferred biologicals for inflammatory bowel disease will beconsidered only for cases in which there is documentation of a previous trialand therapy failure with a preferred agent.♦ Crohn’s disease. Payment will be considered following an inadequateresponse to two preferred conventional therapies, such asaminosalicylates (mesalamine, sulfasalazine), corticosteroids,azathioprine/6-mercaptopurine, or methotrexate.♦ Ulcerative colitis (moderate to severe). Payment will be consideredfollowing an inadequate response to two preferred conventional therapiesincluding aminosalicylates and azathioprine/6-mercaptopurine.Use form 470-4523, Request for Prior Authorization: Biologicals forInflammatory Bowel Disease, to request prior authorization. Click here to seea sample of the form.