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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage58DateAugust 1, 2013♦ Congenital heart disease (CHD):The patient is less than 24 months of age at start of therapy and hashemodynamically significant congenital heart disease further defined byany of the following:• Receiving medication to control congestive heart failure,• Moderate to severe pulmonary hypertension, or• Cyanotic congenital heart disease.♦ Severe immunodeficiency:The patient is less than 24 months of age at start of therapy and hassevere immunodeficiencies (e.g., severe combined immunodeficiency oradvanced acquired immunodeficiency syndrome).Use form 470-4110, Request for Prior Authorization: Palivizumab (Synagis ® ),to request prior authorization. Click here to see a sample of the form.60. Proton Pump InhibitorsPrior authorization is not required for the preferred proton pump inhibitors(PPI) for a cumulative 60 days of therapy per 12-month period.Prior authorization will be required beginning the first day of therapy for allnonpreferred proton pump inhibitors as indicated on the Iowa MedicaidPreferred Drug List. Payment for a nonpreferred proton pump inhibitor willbe authorized only for cases with documentation of previous trial and therapyfailure with three preferred products.Prior authorization is required for any PPI usage longer than 60 days or morefrequently than one 60-day course per 12-month period. The 12-monthperiod is patient-specific and begins 12 months before the requested date ofprior authorization.Payment for usage beyond these limits will be authorized for cases in whichthere is a diagnosis of:♦ Specific hypersecretory conditions (Zollinger-Ellison syndrome, systemicmastocytosis, multiple endocrine adenomas).♦ Barrett’s esophagus.♦ Erosive esophagitis.