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

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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.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage48DateAugust 1, 201344. Ivacaftor (Kalydeco )Prior authorization is required for Kalydeco (Ivacaftor). Payment will beconsidered for patients when the following criteria are met:♦ Patient is six years of age or older; and♦ Has a diagnosis of cystic fibrosis with a G551D mutation in the CFTR geneas detected by an FDA-cleared cystic fibrosis mutation test; and♦ Prescriber is a cystic fibrosis specialist or pulmonologist; and♦ Patient does not have one of the following infections: Burkholderiacenecepacia, dolosa, or Mycobacterium abcessus.Use form 470-5117, Request for Prior Authorization: Ivacaftor (Kalydeco ),to request prior authorization. Click here to see a sample of the form.45. Ketorolac Tromethamine (Toradol ® )Prior authorization is required for ketorolac tromethamine, a nonsteroidalanti-inflammatory drug indicated for short-term management of moderatelysevere, acute pain (up to five days). It is not indicated for minor or chronicconditions. This product carries a Black Box Warning.Initiate therapy with IV/IM and use oral ketorolac tromethamine only as acontinuation therapy to ketorolac tromethamine IV/IM. The combinedduration of use of IV/IM and oral is not to exceed five days. Payment will beapproved for the preferred product under the following conditions:♦ For oral therapy, documentation of recent IM/IV ketorolac tromethamineinjection including administration date and time, and the total number ofinjections given.♦ Request falls within the manufacturer’s dosing guidelines. Maximum oraldose is 40 mg/day. Maximum IV/IM dose is 120 mg/day. Maximumintranasal dose is 126 mg/day. Maximum duration of therapy is 5 daysper month.♦ Diagnosis indicating moderately severe, acute pain.Requests for IV/IM and intranasal ketorolac must document previous trialsand therapy failures with at least two preferred nonsteroidal antiinflammatorydrugs at therapeutic doses.
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