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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage41DateAugust 1, 201330. Dornase Alfa (Pulmozyme ® )Prior authorization is required for Pulmozyme ® . Payment will be authorizedonly for cases in which there is a diagnosis of cystic fibrosis.Use form 470-4104, Request for Prior Authorization: Miscellaneous, torequest prior authorization. Click here to see a sample of the form.31. Eplerenone (Inspra ® )Prior authorization is required for Inspra ® . Payment will be authorized only incases where there is documented trial and therapy failure on Aldactone ® ordocumented cases of gynecomastia from Aldactone ® therapy.Use form 470-4104, Request for Prior Authorization: Miscellaneous, torequest prior authorization. Click here to see a sample of the form.32. Erythropoiesis Stimulating AgentsPrior authorization is required for erythropoiesis stimulating agents prescribedfor outpatients for the treatment of anemia.Payment for nonpreferred erythropoiesis stimulating agents will beauthorized only for cases in which there is documentation of previous trialand therapy failure with a preferred agent.Patients who meet all of the following criteria may receive prior authorizationfor the use of erythropoiesis stimulating agents:♦ Hemoglobin less than 10g/dL. If renewal of prior authorization is beingrequested, a hemoglobin less than 11g/dL (or less than 10g/dL forpatients with Chronic Kidney Disease (CKD) not on dialysis) will berequired for continued treatment. Hemoglobin laboratory values must bedated within four weeks of the prior authorization request.♦ Transferrin saturation greater than or equal to 20 percent (transferrinsaturation is calculated by dividing serum iron by the total iron bindingcapacity), ferritin levels greater than or equal to 100 mg/ml, or onconcurrent therapeutic iron therapy.Transferrin saturation or ferritin levels must be dated within three monthsof the prior authorization request.