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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage40DateAugust 1, 2013♦ Initial authorizations will be approved for 12 weeks with a baseline Centerfor Neurologic Studies Lability Scale (CNS-LS) questionnaire.♦ Subsequent prior authorizations will be considered at six month intervalswith documented efficacy as seen in an improvement in the CNS-LSquestionnaire.Use form 470-5084, Request for Prior Authorization: Dextromethorphan andQuinidine (Nuedexta), to request prior authorization. Click here to see asample of the form.28. Digestive EnzymesPrior authorization is required for all digestive enzymes.Payment for preferred digestive enzymes will be authorized only for cases inwhich there is a clinical diagnosis of malabsorption due to pancreaticinsufficiency.Payment for nonpreferred digestive enzymes will be authorized only forcases in which there is documentation of previous trial and therapy failurewith a preferred agent.Use form 470-4104, Request for Prior Authorization: Miscellaneous, torequest prior authorization. Click here to see a sample of the form.29. Dipeptidyl Peptidase-4 (DPP-4) InhibitorsPrior authorization is required for dipeptidyl peptidase-4 (DPP-4) inhibitorsand DPP-4 inhibitor combinations. Payment will be considered under thefollowing conditions:♦ The patient has a diagnosis of Type 2 diabetes mellitus;♦ The patient is 18 years of age or older; and♦ The patient has not achieved HbgA1C goals using a combination of two ormore antidiabetic medications (metformin, sulfonylurea, thiazolidinedione,or insulin) at maximum tolerated doses unless otherwise contraindicated.Payment for a nonpreferred agent will be authorized only for cases in whichthere is documentation of a previous trial and therapy failure with a preferredagent, unless evidence is provided that use of these agents would bemedically contraindicated.Use form 470-4897, Request for Prior Authorization: DPP-4 Inhibitors, torequest prior authorization. Click here to see a sample of the form.