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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage54DateAugust 1, 2013Approvals will be granted for subsequent six-month periods only after a drugfreeinterval to assess the need for continued therapy.Payment for nonpreferred nonparenteral vasopressin derivatives will beauthorized only for cases in which there is documentation of trial and therapyfailure with a preferred agent.Use form 470-4107, Request for Prior Authorization: NonparenteralVasopressin Derivatives of Posterior Pituitary Hormone Products, to requestprior authorization. Click here to see a sample of the form.55. Nonpreferred DrugsPrior authorization is required for nonpreferred drugs as specified on the IowaMedicaid Preferred Drug List.Payment for a nonpreferred medication will be authorized only for cases inwhich there is documentation of previous trial and therapy failure with apreferred agent, unless evidence is provided that use of these agents ismedically contraindicated.Use form 470-4108, Request for Prior Authorization: Non-Preferred Drug, torequest prior authorization. Click here to see a sample of the form.56. Nonsteroidal Anti-Inflammatory DrugsPrior authorization is required for all nonpreferred nonsteroidal antiinflammatorydrugs (NSAIDs) and COX-2 inhibitors. Prior authorization is notrequired for preferred nonsteroidal anti-inflammatory drugs or COX-2inhibitors.♦ Requests for a nonpreferred NSAID must document previous trials andtherapy failures with at least three preferred NSAIDs.♦ Requests for a nonpreferred COX-2 inhibitor must document previoustrials and therapy failures with three preferred NSAIDs, two of which mustbe a preferred COX-2 preferentially selective NSAID.♦ Requests for a nonpreferred topical NSAID must document previous trialsand therapy failures with three preferred NSAIDs. The trials must includetwo preferred COX-2 preferentially selective NSAIDs and the oral drug ofthe same chemical entity. In addition, the use of a topical deliverysystem must be deemed medically necessary.