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Iowa Department of Human Services

FAX Completed Form To

1 (800) 574-2515

Request for Prior Authorization

Provider Help Desk

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

1 (877) 776-1567

(PLEASE PRINT – ACCURACY IS IMPORTANT)

IA Medicaid Member ID #

Patient name

DOB

Patient address

Provider NPI

Prescriber name

Phone

Prescriber address

Fax

Pharmacy name

Address

Phone

Prescriber must complete all information above. It must be legible, correct, and complete or form will be returned.

Pharmacy NPI

Pharmacy fax

NDC

Prior authorization is required for all non-preferred nonsteroidal anti-inflammatory drugs (nsaids) and COX-2 inhibitors. Prior authorization is

not required for preferred nsaids or COX-2 inhibitors. 1. Requests for a non-preferred nsaid must document previous trials and therapy

failures with at least three preferred nsaids. 2. Requests for a non-preferred COX-2 inhibitor must document previous trials and therapy

failures with three preferred nsaids, two of which must be preferred COX-2 preferentially selective nsaids. 3) Requests for a non-preferred

topical nsaid must document previous trials and therapy failures with three preferred nsaids. The trials must include two preferred COX-2

preferentially selective nsaids and the oral drug of the same chemical entity. In addition, the use of a topical delivery system must be deemed

medically necessary. 4) Requests for a non-preferred extended release nsaid must document previous trials and therapy failures with three

preferred nsaids, one of which must be the preferred immediate release nsaid of the same chemical entity at a therapeutic dose that resulted

in a partial response with a documented intolerance. The required trials may be overridden when documented evidence is provided that use

of these agents would be medically contraindicated.

Preferred

Non-Preferred

(No PA required)

(PA required for all products)

 Arthrotec

 Indomethacin ER*

 Tivorbex

Diclofenac Sod./Pot.

Meloxicam

(COX-2)

 Celebrex

 Ketoprofen ER

 Tolmetin Sod

Diclofenac Sod. EC/DR

Nabumetone

(COX-2)

 Celecoxib

 Meclofenamate Sod

 Vivlodex

Etodolac 400mg/500mg

Naprosyn Susp.

 Diclofenac ER/XR*

 Naprelan

 Voltaren Gel

Flurbiprofen

Naproxen

 EC-Naprosyn

 Oxaprosin

 Voltaren XR

Ibuprofen

Naproxen EC/ER

Naproxen Sodium 550mg  Etodollac CR/ER/XR  Pennsaid

 Zipsor

Ibuprofen Susp.

 Fenoprofen

 Piroxicam

 Zorvolex

Indomethacin

Salsalate

 Flector Patch

 Ponstel

Ketoprofen

Sulindac

 Other (specify) _______________________________________

Strength_____________ Dosage Instructions_________________________Quantity_______ Days Supply________

Diagnosis:_______________________________________________________________________________________

Preferred Drug Trial 1: Drug Name& Dose__________________________________ Trial Dates:__________________

Failure Reason____________________________________________________________________________________

Preferred Drug Trial 2: Drug Name& Dose__________________________________ Trial Dates:__________________

Failure Reason____________________________________________________________________________________

Preferred Drug Trial 3: Drug Name& Dose__________________________________ Trial Dates:__________________

Failure Reason____________________________________________________________________________________

Medical Necessity for alternative delivery system: _________________________________________________________

Medical or contraindication reason to override trial requirements: _____________________________________________

Reason for use of Non-Preferred drug requiring prior approval:_______________________________________________

Attach lab results and other documentation as necessary.

Prescriber signature (Must match prescriber listed above.)

Date of submission

IMPORTANT NOTE: In evaluating requests for prior authorization the consultant will consider the treatment from the standpoint of

medical necessity only. If approval of this request is granted, this does not indicate that the member continues to be eligible for

Medicaid. It is the responsibility of the provider who initiates the request for prior authorization to establish by inspection of the

member’s Medicaid eligibility card and, if necessary by contact with the county Department of Human Services, that the member

continues to be eligible for Medicaid.

470-4109 (Rev. 6/16)

Request Form For Prior Authorization Nonsteroidal Anti-Inflammatory Drugs - Iowa Department Of Human Services

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