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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage51DateAugust 1, 2013The required trials may be overridden when documented evidence is providedthat use of these preferred agents would be medically contraindicated.Payment for a nonpreferred alternative delivery system will be consideredonly for cases in which the use of an alternative delivery system is deemedmedically necessary and there is a previous trial and therapy failure with apreferred alternative delivery system if available.Use form 470-4705, Request for Prior Authorization: Modified Formulations,to request prior authorization. Click here to see a sample of the form.50. Muscle RelaxantsPrior authorization is required for nonpreferred muscle relaxants. Paymentfor nonpreferred muscle relaxants will be authorized only for cases in whichthere is documentation of previous trials and therapy failure with at leastthree preferred muscle relaxants.Requests for carisoprodol will be approved for a maximum of 120 tablets per180 days at a maximum of 4 tablets per day when the criteria for coverageare met.If a nonpreferred long-acting medication is requested, one trial must includethe preferred immediate-release product of the same chemical entity at atherapeutic dose, unless evidence is provided that use of these productswould be medically contraindicated.Use form 470-4105, Request for Prior Authorization: Muscle Relaxants, torequest prior authorization. Click here to see a sample of the form.51. Narcotic Agonist-Antagonist Nasal SpraysPrior authorization is required for narcotic agonist-antagonist nasal sprays.The member’s diagnosis must be supplied for consideration.If the use is for the treatment of migraine headaches, documentation ofcurrent prophylactic therapy or documentation of previous trials and therapyfailures with two different prophylactic medications must be provided. Theremust also be documented treatment failure or contraindication to triptans forthe acute treatment of migraines.