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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage86DateAugust 1, 2013Use form 470-4850, Request for Prior Authorization: ThrombopoietinReceptor Agonists, to request prior authorization. Click here to see a sampleof the form.71. Topical RetinoidsPrior authorization is required for all prescription topical retinoid products.Payment for prescription topical retinoid products will be considered underthe following conditions:♦ Patients with a diagnosis of skin cancer, lamellar ichthyosis, or Darier’sdisease will receive automatic approval for lifetime use of topical retinoidproducts.♦ Payment will be authorized when the patient has had previous trial andtherapy failure with:• A preferred over-the-counter benzoyl peroxide product, and• Two preferred topical or oral antibiotics for the treatment of mild tomoderate acne (noninflammatory and inflammatory) or drug-inducedacne.EXCEPTION: Trials and therapy failure are not required for patientspresenting with a preponderance of comedonal acne.♦ Payment for nonpreferred topical retinoid products will be authorized onlyfor cases in which there is documentation of previous trial and therapyfailure with a preferred agent.♦ Requests for nonpreferred combination products wil be considered onlyafter documentation of separate trials and therapy failures with theindividual ingredients.♦ Trial and therapy failure with a preferred topical antipsoriatic agent willnot be required for tazorac for a psoriasis diagnosis.The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Use form 470-4114, Request for Prior Authorization: Topical Retinoids forAcne, to request prior authorization. Click here to see a sample of the form.