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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage87DateAugust 1, 201372. Vemurafenib (Zelboraf)Prior authorization is required for vemurafenib (Zelboraf). Payment will beconsidered for patients when the following criteria are met:♦ Patient is 18 years of age or older; and♦ Has a diagnosis of unresectable or metastatic melanoma with BRAFV600Emutation as detected by an FDA-approved test; and♦ Prescriber is an oncologist.If the criteria for coverage are met, authorizations will be given at threemonth intervals. Updates on disease progression must be provided with eachrenewal request. If disease progression is noted, therapy will not becontinued.Use form 470-5136, Request for Prior Authorization: Vemurafenib(Zelboraf), to request prior authorization. Click here to see a sample of theform.73. Vilazodone (Viibryd )Prior authorization is required for Viibryd . Requests for doses above themanufacturer recommended dose will not be considered. Payment will beconsidered for patients when the following criteria are met:♦ The patient has a diagnosis of Major Depressive Disorder (MDD) and is 18years of age and older; and♦ Documentation of a previous trial and therapy failure at a therapeuticdose with one preferred generic SSRI; and♦ Documentation of a previous trial and therapy failure at a therapeuticdose with one preferred generic SNRI; and♦ Documentation of a previous trial and therapy failure at a therapeuticdose with an additional generic antidepressant from any class.The required trials may be overridden when documented evidence is providedthat the use of these agents would be medically contraindicated.Use form 470-5098, Request for Prior Authorization: Vilazodone (Viibryd ),to request prior authorization. Click here to see a sample of the form.