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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage37DateAugust 1, 201322. Chronic Pain Syndrome AgentsPrior authorization is required for duloxetine (Cymbalta ® ), pregabalin(Lyrica ® ), and milnacipran (Savella ). Payment will be considered under thefollowing conditions:♦ A diagnosis of fibromyalgia (Cymbalta ® , Lyrica ® , and Savella ) with:• A trial and therapy failure at a therapeutic dose with three drugs fromthree distinct therapeutic classes from the following: tricyclicantidepressant, muscle relaxant, SSRI/SNRI, tramadol, or gabapentin,and• Documented non-pharmacologic therapies (cognitive behaviortherapies, exercise, etc.), and• Documentation of a previous trial and therapy failure at a therapeuticdose with Savella when Cymbalta ® and Lyrica ® are requested.♦ A diagnosis of postherpetic neuralgia (Lyrica ® ) with a trial and therapyfailure at a therapeutic dose with at least two drugs from two distincttherapeutic classes from the following: tricyclic antidepressant, topicallidocaine, valproate, carbamazepine, or gabapentin♦ A diagnosis of diabetic peripheral neuropathy (Cymbalta ® and Lyrica ® )with a trial and therapy failure at a therapeutic dose with at least twodrugs from two distinct therapeutic classes from the following: tricyclicantidepressant, topical lidocaine, tramadol, or gabapentin♦ A diagnosis of partial onset seizures, as adjunct therapy (Lyrica ® )♦ A diagnosis of major depressive disorder or generalized anxiety disorder(Cymbalta ® )♦ A diagnosis of chronic musculoskeletal pain (Cymbalta ® ) with a trialand therapy failure at a therapeutic dose with at least three drugs fromthree distinct therapeutic classes from the following: NSAIDs, opioids,tramadol, or tricyclic antidepressants.Requests for concomitant use of these agents for an indicated chronic paindiagnosis may only be considered once each agent has been tried atmaximum tolerated dose separately. Duplicate use of drugs from the sametherapeutic category will not be considered.Use form 470-4551, Request for Prior Authorization: Chronic Pain Syndrome,to request prior authorization. Click here to see a sample of the form.