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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage84DateAugust 1, 2013Use form 470-4113, Request for Prior Authorization: Serotonin 5-HT1Receptor Agonists, to request prior authorization. Click here to see a sampleof the form.67. Short-Acting NarcoticsPrior authorization is required for all nonpreferred short-acting narcotics.Payment will be considered for cases in which there is documentation ofprevious trial and therapy failures with three chemically distinct preferredshort-acting narcotics (based on narcotic ingredient only) at therapeuticdoses, unless evidence is provided that use of these products would bemedically contraindicated.Use form 470-4899, Request for Prior Authorization: Short Acting Narcotics,to request prior authorization. Click here to see a sample of the form.68. Smoking Cessation Therapy-OralPrior authorization is required for varenicline (Chantix) or bupropion SRthat is FDA approved for smoking cessation. Requests for authorization mustinclude:♦ Diagnosis of nicotine dependence and referral to the Quitline Iowaprogram for counseling.♦ Confirmation of enrollment and ongoing participation in the Quitline Iowacounseling program is required for approval and continued coverage.Approvals will be granted only for patients 18 years of age or older.♦ The duration of therapy is initially limited to 12 weeks within a 12-monthperiod.♦ For patients who have successfully stopped smoking at the end of 12weeks, an additional course of 12 weeks treatment will be considered witha prior authorization request. The maximum duration of approvabletherapy is 24 weeks within a 12-month period.♦ Requests for varenicline to be used in combination with bupropion SR thatis FDA-indicated for smoking cessation or nicotine replacement therapywill not be approved.♦ The 72-hour emergency supply rule does not apply for drugs used for thetreatment of smoking cessation.