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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage52DateAugust 1, 2013For other pain conditions, there must be documentation of treatment failureor contraindication to oral administration.Payment for nonpreferred narcotic agonist-antagonist nasal sprays will beauthorized only for cases in which there is documentation of previous trialand therapy failure with a preferred agent.Quantities are limited to 2 bottles or 5 milliliters per 30 days. Payment fornarcotic agonist-antagonist nasal sprays beyond this limit will be consideredon an individual basis after review of submitted documentation.Use form 470-4106, Request for Prior Authorization: Narcotic Agonist/Antagonist Nasal Sprays, to request prior authorization. Click here to see asample of the form.52. Nebivolol (Bystolic ® )Prior authorization is required for Bystolic ® . Payment will be considered incases where there are documented trials and therapy failures with twopreferred cardio-selective beta-blockers of a different chemical entity at atherapeutic dose. The required trials may be overridden when documentedevidence is provided that the use of these agents would be medicallycontraindicated.Use form 470-5099, Request for Prior Authorization: Nebivolol (Bystolic ® ), torequest prior authorization. Click here to see a sample of the form.53. Nicotine Replacement ProductsPrior authorization is required for over-the-counter nicotine replacementpatches, gum or lozenges, and prescription nicotine nasal spray or inhaler.Requests for authorization must include:♦ Diagnosis of nicotine dependence and referral to the Quitline Iowaprogram for counseling.♦ Confirmation of enrollment in the Quitline Iowa counseling program isrequired for approval. Continuation therapy is available only withdocumentation of ongoing participation in the Quitline Iowa program.♦ Approvals will be granted only for patients 18 years of age and older.