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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage47DateAugust 1, 201342. Insulin Pens, Pre-filledPrior authorization is required for pre-filled insulin pens. Prior authorization isgranted when documentation indicates:♦ The member’s visual or motor skills are impaired to such that the membercannot accurately draw up the insulin, and♦ There is no caregiver available to provide assistance.Prior authorization for nonpreferred insulin pens will be granted only forcases in which there is documentation of previous trial and therapy failurewith a preferred agent.Use form 470-4111, Request for Prior Authorization: Insulin, Pre-Filled Pens,to request prior authorization. Click here to see a sample of the form.43. Isotretinoin (Oral)Prior authorization is required for oral isotretinoin therapy. Payment will beapproved for preferred oral isotretinoin products for acne under the followingconditions:♦ There are documented trials and therapy failures of systemic antibiotictherapy and topical tretinoin therapy. Trials and failures of systemicantibiotic therapy and topical tretinoin therapy are not required forapproval for treatment of acne conglobata.♦ Patients and providers must be registered in, and meet all requirementsof, the iPLEDGE (https://www.ipledgeprogram.com/) risk managementprogram.Payment for nonpreferred oral isotretinoin products will be authorized only forcases in which there is documentation of trials and therapy failure with apreferred agent. Initial authorization will be granted for up to 20 weeks. Aminimum of two months without therapy is required to consider subsequentauthorizations.Use form 470-4101, Request for Prior Authorization: Isotretinoin (Oral), torequest prior authorization. Click here to see a sample of the form.