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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage59DateAugust 1, 2013♦ Symptomatic gastroesophageal reflux after documentation of previoustrials and therapy failure with at least one histamine H2-receptorantagonist at full therapeutic doses.Requests for PPIs exceeding one unit per day will be considered afterdocumentation of a therapeutic trial and therapy failure with concomitantuse of once daily PPI dosing and a bedtime dose of a histamineH2-receptor antagonist. Upon failure of the combination therapy,subsequent requests for PPIs exceeding one unit per day will beconsidered on a short term basis (up to three months).After the three-month period, a retrial of the recommended once dailydosing will be required. A trial of the recommended once daily dosing willbe required on an annual basis for those patients continuing to needdoses beyond one unit per day.♦ Recurrent peptic ulcer disease after documentation of:• Previous trials and therapy failure with at least one histamineH2-receptor antagonist at full therapeutic doses, and• Either failure of Helicobacter pylori treatment or a negativeHelicobacter pylori test result.Use form 470-4112, Request for Prior Authorization: Proton Pump Inhibitors,to request prior authorization. Click here to see a sample of the form.61. Pulmonary Arterial Hypertension AgentsPrior authorization is required for agents used to treat pulmonaryhypertension. Payment will be approved for the diagnosis of pulmonaryarterial hypertension.Use form 470-4327, Request for Prior Authorization: Pulmonary ArterialHypertension Agents, to request prior authorization. Click here to see asample of the form.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage60DateAugust 1, 201362. Quantity Limit Overridea. Initial 15-Day LimitDrugs that have been identified with high side effect profiles, highdiscontinuations rates, or frequent dose adjustments are limited to a15-day initial supply. The initial prescription supply limit ensures costeffectiveness without waste of unused medications.These drugs are identified on the Fifteen Day Initial Prescription SupplyLimit list located on the website www.iowamedicaidpdl.com under thePreferred Drug Lists tab and the Billing/Quantity Limits tab.To request authorization for an initial supply longer than 15 days,submit form 470-5038, Request for Fifteen Day Initial PrescriptionSupply Override, for consideration. Click here for a sample of the form.The form is located at www.iowamedicaidpdl.com under PA Forms.Documentation of medical necessity, excluding patient convenience, isrequired for consideration of the 15-day initial supply override.b. Monthly LimitsDesignated drugs have specific quantity limitations. These drugs areidentified on the Iowa Medicaid Quantity Limit Chart posted on thewebsite www.iowamedicaidpdl.com under the Billing/Quantity Limits tab.Medication doses that use multiple, lower-strength tablets should beconsolidated to the higher-strength tablet. Quantity limits based on thecompendia are also enforced. Please view the current list atwww.iowamedicaidpdl.com under Quantity Limits.Prior authorization is required if there is a reason the higher tabletstrength cannot be used or a medical rationale for use of higher thanrecommended dosing.Providers should submit a Prior Authorization request for overrideconsideration. Use form 470-4556, Request for Prior Authorization:Request for Quantity Limit Override, to request prior authorization.Click here to see a sample of the form. The form is located atwww.iowamedicaidpdl.com under PA Forms.
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