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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsPage1DateAugust 1, 2013TABLE OF CONTENTSPageCHAPTER III. PROVIDER-SPECIFIC POLICIES .................................................. 1A. GENERAL PHARMACY GUIDELINES ............................................................... 11. Definitions ......................................................................................... 12. Entities Involved in Developing Medicaid Drug Policies ............................. 5a. Drug Utilization Review Commission ............................................... 5b. Pharmaceutical and Therapeutics Committee ................................... 63. Pharmacies Eligible to Participate .......................................................... 7a. Licensure .................................................................................... 7b. Survey Participation ..................................................................... 74. Pharmacist Responsibilities................................................................... 8a. Prospective Drug Utilization Review ................................................ 8b. Dispensing Requirements .............................................................. 8c. Patient Counseling ....................................................................... 8d. Reason for Denial ........................................................................ 95. Drug Use Review ............................................................................... 10B. COVERAGE OF SERVICES ........................................................................... 111. Prescription Requirements ................................................................... 11a. Prescriber Qualifications .............................................................. 11b. Prescriber Guidelines ................................................................... 122. Drugs Excluded From Coverage ........................................................... 123. Drugs for Medicare Eligibles ................................................................ 134. Preferred or Recommended Drugs ........................................................ 135. Nonpreferred Drugs ........................................................................... 146. Newly Released Drugs ........................................................................ 14a. New Drug Entities ....................................................................... 14b. Exceptions to the Nonpreferred Default Policy for New PDL Drugs ...... 15c. Existing PDL Drugs With Supplemental Rebates .............................. 157. Nonprescription Drugs ........................................................................ 168. Medical Supplies ................................................................................ 18C. PRIOR AUTHORIZATION REQUIREMENTS ..................................................... 181. Completing a Prior Authorization Request .............................................. 212. Submitting a Prior Authorization Request .............................................. 233. Prior Authorization Response ............................................................... 244. ADD/ADHD/Narcolepsy Agents............................................................. 255. Alpha 2 Agonists, Extended-Release ....................................................... 26
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsPage2DateAugust 1, 2013Page6. Alpha 1 Proteinase Inhibitor Enzymes ..................................................... 267. Amylino Mimetic (Symlin ® ) ................................................................. 278. Angiotensin Receptor Blocker (ARB) ..................................................... 279. Anti-Acne Products ............................................................................. 2810. Antiemetic-5HT3 Receptor Antagonists/Substance P Neurokinin Products ... 2811. Antifungal Therapy ............................................................................. 3012. Antihistamines .................................................................................. 3013. Anti-Thrombotics ............................................................................... 3114. Becaplermin (Regranex ® ) ................................................................... 3115. Benzodiazepines ................................................................................ 3216. Biologicals for Ankylosing Spondylitis .................................................... 3217. Biologicals for Arthritis ........................................................................ 3318. Biologicals for Inflammatory Bowel Disease ........................................... 3419. Biologicals for Plaque Psoriasis ............................................................. 3520. Buprenorphine (Butrans) Transdermal System .................................... 3521. Buprenorphine/Naloxone (Suboxone ® ).................................................. 3522. Chronic Pain Syndrome Agents ............................................................ 3723. Colchicine (Colcrys ® ).......................................................................... 3824. Concurrent IM/PO Antipsychotic Use ..................................................... 3825. Crizotinib (Xalkori ® ) ........................................................................... 3926. Dalfampridine (Ampyra)................................................................... 3927. Dextromethorphan and Quinidine (Nuedexta)...................................... 3928. Digestive Enzymes ............................................................................. 4029. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors .............................................. 4030. Dornase Alfa (Pulmozyme ® ) ................................................................ 4131. Eplerenone (Inspra ® ) ......................................................................... 4132. Erythropoiesis Stimulating Agents ........................................................ 4133. Extended-Release Formulations ........................................................... 4234. Febuxostat (Uloric ® )........................................................................... 4235. Fentanyl, Short-Acting Oral Products .................................................... 4236. Fingolimod (Gilenya) ....................................................................... 4337. Granulocyte Colony Stimulating Factor Agents ....................................... 4338. Growth Hormones .............................................................................. 4439. Hepatitis C Protease Inhibitors-Oral (Incivek and Victrelis ) ................... 4540. Immunomodulators – Topical .............................................................. 4641. Incretin Mimetic (Byetta ® and Victoza ® ) ................................................ 4642. Insulin Pens, Pre-filled ........................................................................ 4743. Isotretinoin (Oral).............................................................................. 4744. Ivacaftor (Kalydeco )......................................................................... 4845. Ketorolac Tromethamine (Toradol ® ) ..................................................... 4846. Lidocaine Patch (Lidoderm ® ) ............................................................... 49
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