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

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.