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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage49DateAugust 1, 2013Use form 470-4102, Request for Prior Authorization: KetorolacTromethamine (Toradol ® ), to request prior authorization. Click here to see asample of the form.46. Lidocaine Patch (Lidoderm ® )Prior authorization is required for topical lidocaine patches (Lidoderm ® ).Payment will be considered for a diagnosis of pain associated with postherpeticneuralgia following a previous treatment failure with a preferredagent at therapeutic dose from two of the following: tricyclic antidepressant,opioid, gabapentin, carbamazepine, or valproic acid.A maximum of 30 patches may be dispensed with the initial prescription todetermine efficacy.Use form 470-4898, Request for Prior Authorization: Lidocaine Patch(Lidoderm ® ), to request prior authorization. Click here to see a sample of theform.47. Linezolid (Zyvox ® )Prior authorization is required for linezolid (Zyvox ® ). Payment for Zyvox ® willbe authorized when there is documentation that:♦ The prescriber is an infectious disease physician or has consulted aninfectious disease physician. (Telephone consultation is acceptable.)♦ The member has an active infection that meets one of the followingdiagnostic criteria:• Vancomycin-resistant enterococcus (VRE) when no alternativeregimens with documented efficacy are available and VRE is not inlower urinary tract.• VRE in the lower urinary tract if severe renal insufficiency exists or thepatient is receiving hemodialysis or has known hypersensitivity tonitrofurantoin.• Methicillin-resistant staphylococcus aureus (MRSA) when the patient isintolerant to vancomycin.*• Methicillin-resistant staphylococcus epidermis (MRSE) when the patientis intolerant to vancomycin.*
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage50DateAugust 1, 2013* Severe intolerance to vancomycin is defined as:• Severe rash, immune-complex-mediated, determined to be directlyrelated to vancomycin administration.• Red-man’s syndrome (histamine-mediated), refractory to traditionalcountermeasures (e.g., prolonged IV infusion, premedicated withdiphenhydramine).Use form 470-4275, Request for Prior Authorization: Linezolid (Zyvox ® ), torequest prior authorization. Click here to see a sample of the form.48. Mifepristone (Korlym ® )Prior authorization is required for mifepristone (Korlym ® ). Payment will beconsidered for patients when the following is met:♦ The patient is 18 years of age or older; and♦ Has a diagnosis of endogenous Cushing’s Syndrome with hyperglycemiasecondary to hypercortisolism in patients with Type 2 Diabetes or glucoseintolerance; and♦ Patient must have failure surgery or is not a candidate for surgery; and♦ Prescriber is an endocrinologist.♦ Female patients of reproductive age must have a negative pregnancy testconfirmed within the last seven days and must use a non-hormonalmethod of contraception during treatment and for one month afterstopping treatment.Use form 470-5141, Request for Prior Authorization: Mifepristone (Korlym ® ),to request prior authorization. Click here to see a sample of the form.49. Modified FormulationsPayment for a nonpreferred isomer, pro-drug, or metabolite will beconsidered when the following criteria are met:♦ Previous trial with a preferred parent drug of the same chemical entity ata therapeutic dose that resulted in a partial response with a documentedintolerance; and♦ Previous trial and therapy failure at a therapeutic dose with a preferreddrug of a different chemical entity indicated to treat the submitteddiagnosis if available.
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