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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage81DateAugust 1, 2013Drug ProductQuantityDays’SupplyZyprexa 15 mg (olanzapine) 60 30Zyprexa 20 mg (olanzapine) 60 30Zyprexa Zydis 5 mg (olanzapine) 30 30Zyprexa Zydis 10 mg (olanzapine) 30 30Zyprexa Zydis 15 mg (olanzapine) 60 30Zyprexa Zydis 20 mg (olanzapine) 60 30Zyrtec 1 mg/ml liquid OTC300 30(cetirizine)Zyrtec 5 mg tablet OTC (cetirizine) 30 30Zyrtec 10 mg tablet OTC (cetirizine) 30 30Comments63. Roflumilast (Daliresp)Prior authorization is required for roflumilast (Daliresp ). Payment will beconsidered for patients 18 years of age or older when the following is met:♦ A diagnosis of severe COPD with chronic bronchitis as documented byspirometry results, and♦ A smoking history of ≥ 20 pack-years, and♦ Currently on a long-acting bronchodilator in combination with an inhaledcorticosteroid with documentation of inadequate control of symptoms, and♦ A history of at least one exacerbation in the past year requiring treatmentwith oral glucocorticosteroids.The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Use form 470-5085, Request for Prior Authorization: Roflumilast(Daliresp), to request prior authorization. Click here to see a sample of theform.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage82DateAugust 1, 201364. Sedative/Hypnotics-Non-BenzodiazepinePreferred agents are available without prior authorization (PA). Althoughintermittent therapy is recommended, quantity limits will allow for 30 tabletsper 30 days supply without PA for preferred medications.Prior authorization is required for all nonpreferred nonbenzodiazepinesedative/hypnotics. Payment for nonpreferred nonbenzodiazepinesedative/hypnotics will be authorized only for cases in which there isdocumentation of a previous trial and therapy failure with the preferredagents. Payment for nonpreferred nonbenzodiazepine sedative/hypnotics willbe considered when there is:♦ A diagnosis of insomnia.♦ Medications with a side effect of insomnia (i.e., stimulants) are decreasedin dose, changed to a short-acting product, or discontinued.♦ Enforcement of good sleep hygiene is documented.♦ All medical, neurological, and psychiatric disease states causing chronicinsomnia are being adequately treated with appropriate medication attherapeutic doses.♦ A documented trial and therapy failure with zaleplon.Use form 470-4328, Request for Prior Authorization: Sedative/Hypnotics-Non-Benzodiazepine, to request prior authorization. Click here to see asample of the form.65. Selected Brand-Name DrugsPrior authorization is required for selected brand-name drugs, as determinedby the Department, for which there is available an “A” rated bioequivalentgeneric product, as determined by the federal Food and Drug Administration,unless the brand drug has been designated by the Department as preferred(payable) under the Iowa Medicaid Preferred Drug List.The list of selected brand-name drugs includes the drugs on the FederalUpper Limit (FUL) list at http://www.mslciowa.com/AAC.htm.
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