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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage38DateAugust 1, 201323. Colchicine (Colcrys ® )Prior authorization is not required for colchicine (Colcrys ® ) for the treatmentof acute gout for 3 tablets per 60-day period. Prior authorization is requiredfor colchicine (Colcrys ® ) for the treatment of chronic hyperuricemia/goutprophylaxis or Familial Mediterranean fever. Payment will be consideredunder the following conditions:♦ Chronic hyperuricemia/gout prophylaxis following a trial and therapyfailure at a therapeutic dose with allopurinol or probenecid. A quantitylimit of 60 tablets per 30 days will be applied, when criteria for coverageare met.♦ Familial Mediterranean fever. A maximum quantity limit of 120 tabletsper 30 days will be applied for this diagnosis.The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Use form 470-5059, Request for Prior Authorization: Colchicine (Colcrys ® ),to request prior authorization. Click here to see a sample of the form.24. Concurrent IM/PO Antipsychotic UsePrior authorization is required for concurrent long-acting injectable and oralantipsychotic medications after 12 weeks (84 days) of concomitanttreatment. Consideration of concomitant therapy beyond 12 weeks (84 days)will require documentation of medical necessity.Prior authorization is required for all nonpreferred antipsychotics as indicatedon the Iowa Medicaid Preferred Drug List beginning the first day of therapy.Payment for nonpreferred antipsychotics will be considered only for cases inwhich there is documentation of previous trials and therapy failures with apreferred agent.Use form 470-4594, Request for Prior Authorization: Concurrent IM/POAntipsychotic Utilization, to request prior authorization. Click here to see asample of the form.