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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage42DateAugust 1, 2013♦ For HIV-infected patients, the endogenous serum erythropoietin levelmust be less than or equal to 500 mU/ml to initiate therapy.♦ No evidence of untreated GI bleeding, hemolysis, or vitamin B-12, iron orfolate deficiency.Use form 470-4098, Request for Prior Authorization: ErythropoiesisStimulating Agents, to request prior authorization. Click here to see a sampleof the form.33. Extended-Release FormulationsPayment for a nonpreferred extended-release formulation will be consideredwhen both of the following criteria are met:♦ Previous trial with the preferred immediate-release product of the samechemical entity at a therapeutic dose that resulted in a partial responsewith a documented intolerance, and♦ Previous trial and therapy failure at a therapeutic dose with a preferreddrug of a different chemical entity that is indicated to treat the submitteddiagnosis.Use form 470-4550, Request for Prior Authorization: Extended ReleaseFormulations, to request prior authorization. Click here to see a sample ofthe form.34. Febuxostat (Uloric ® )Prior authorization is required for febuxostat (Uloric ® ). Payment forfebuxostat (Uloric ® ) will only be considered for cases in which there is adiagnosis of gout still persistent while currently using 300 mg per day of apreferred allopurinol product unless documentation is provided that such astrial would be medically contraindicated.Use form 470-4849, Request for Prior Authorization: Febuxostat (Uloric ® ), torequest prior authorization. Click here to see a sample of the form.35. Fentanyl, Short-Acting Oral ProductsPrior authorization is required for short-acting oral fentanyl products.Payment will be authorized only if the diagnosis is for breakthrough cancerpain in opioid-tolerant patients. This product carries a Black Box Warning.