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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage55DateAugust 1, 2013♦ Requests for a nonpreferred extended release NSAID must documentprevious trials and therapy failures with three preferred NSAIDs, one ofwhich must be the preferred.The required trials may be overridden when documented evidence is providedthat use of these agents would be medically contraindicated.Use form 470-4109, Request for Prior Authorization: Nonsteroidal Anti-Inflammatory Drugs, to request prior authorization. Click here to see asample of the form.57. Omalizumab (Xolair ® )Prior authorization is required for omalizumab (Xolair ® ). Payment for Xolair ®will be authorized when the following criteria are met:♦ Patient has a diagnosis of moderate to severe persistent asthma for atleast one year; and♦ Patient is 12 years of age or older; and♦ Pretreatment IgE level is between 30 IU/ml and 700 IU/ml; and♦ Patient’s weight is between 30 kg and 150 kg; and♦ History of a positive skin or RAST test to a perennial aeroallergen; and♦ Prescriber is an allergist, immunologist, or pulmonologist; and♦ Patient is currently using a high dose inhaled corticosteroid and longactingbeta-agonist, is compliant with therapy and asthma symptoms arenot adequately controlled after at least three months of therapy.♦ Patient must have access to an EpiPen to treat allergic reactions that mayoccur after administration of Xolair ® .If the criteria for coverage are met, the initial authorization will be given for16 weeks to assess the need for continued therapy. Requests forcontinuation of therapy will not be granted for patients who have not shownadequate response to Xolair ® therapy and for patients who do not continueconcurrent use with a high dose inhaled corticosteroid and long-acting betaagonist.The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Use form 470-4279, Request for Prior Authorization: Omalizumab (Xolair ® ),to request prior authorization. Click here to see a sample of the form.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage56DateAugust 1, 201358. Oxycodone ER/CR (OxyContin ® )Extended release oxycodone/OxyContin ® is nonpreferred except for membersbeing treated for cancer related pain. Prior authorization at any dose twicedaily for cancer related pain will be approved. For all other diagnoses,payment will be considered under the following conditions:♦ There is documentation of previous trials and therapy failures with twochemically distinct preferred long-acting narcotics (such as morphinesulfate ER, Opana ER, and methadone) at therapeutic doses, and♦ A trial and therapy failure with fentanyl patch at maximum tolerated dose,and♦ A signed chronic opioid therapy management plan between the prescriberand patient must be included with the prior authorization.♦ The prescriber must review the patient’s use of controlled substanceson the Iowa Prescription Monitoring program website athttps://pmp.iowa.gov/IAPMPWebCenter/ prior to requesting theprior authorization.♦ Requests will only be considered for 12 hour dosing.The required trials may be overridden when documented evidence is providedthat use of these agents would be medically contraindicated.Use form 470-4409, Request for Prior Authorization: Oxycodone ER/CR(OxyContin ® ), to request prior authorization. Click here to see a sample ofthe form.59. Palivizumab (Synagis ® )Respiratory Syncytial Virus (RSV) season is defined by the centers for diseasecontrol and prevention of the United States Department of Health and HumanServices and described in the RSV surveillance reports published annually inthe Morbidity and Mortality Weekly Report (MMWR) and available athttp://www.cdc.gov/surveillance/nrevss/rsv/reports.html.♦ Medicaid will use virology data provided by the Iowa Department of PublicHealth (IDPH) to prospectively estimate the start of the RSV season andfollow the virology data to the end of the season.
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