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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage88DateAugust 1, 201374. Vitamins, Minerals and Multiple VitaminsPayment for vitamins, minerals, and multiple vitamins for treatment ofspecific conditions will be approved when:♦ A specific vitamin or mineral deficiency disease is diagnosed; or♦ A member aged 20 or under has a diagnosed disease that inhibits thenutrition absorption process as a secondary effect of the disease.Prior approval is not required for prescribed multi-vitamins with or withoutiron or vitamin D supplements for patients under 12 months of age or aprescription product primarily classified as a blood modifier if that productdoes not contain more than three vitamins and minerals, or for productsprincipally marketed as prenatal vitamin-mineral supplements.Prior authorization is not required for a vitamin and mineral productprincipally marketed for use as a dietary supplement during pregnancy andlactation.Use form 470-4115, Request for Prior Authorization: Vitamins & Minerals, torequest prior authorization. Click here to see a sample of the form.75. Vusion OintmentPrior authorization is required for Vusion ointment. Payment will beconsidered only for cases in which there is documentation of previous trialsand therapy failures with (1) over-the-counter miconazole 2% cream(payable with a prescription) and (2) nystatin cream or ointment, unlessevidence is provided that use of these agents would be medicallycontraindicated.Use form 470-4655, Request for Prior Authorization: Vusion Ointment, torequest prior authorization. Click here to see a sample of the form.