Request For Prior Authorization Form

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AmeriHealth Caritas Iowa
Request for Prior Authorization
Nonsteroidal Anti-Inflammatory Drugs
Form applies to IA Health Link and hawk-i plans.
Please print – accuracy is important.
Fax completed form to 1-855-825-2714. Provider Help Desk: 1-855-328-1612.
AmeriHealth Caritas Iowa member ID #:
Patient name:
Patient address:
DOB:
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.
Please note: AmeriHealth Caritas Iowa uses Iowa Medicaid Enterprise criteria. For complete criteria, please consult
Preferred (No PA required)
Non-Preferred (PA required for all products)
Diclofenac Sod./Pot.
Meloxicam (COX-2)
□ Arthrotec
□ Indomethacin ER*
□ Tivorbex
Nabumetone (COX-2)
Diclofenac Sod. EC/DR
□ Celebrex
□ Ketoprofen ER
□ Tolmetin Sod
Naprosyn Susp.
□ Meclofenamate Sod
□ Vivlodex
Etodolac 400mg/500mg
□ Celecoxib
Naproxen
Flurbiprofen
□ Diclofenac ER/XR*
□ Naprelan
□ Voltaren Gel
Naproxen EC/ER
Ibuprofen
□ EC-Naprosyn
□ Oxaprosin
□ Voltaren XR
Naproxen Sodium 550mg
Ibuprofen Susp.
Salsalate
□ Etodollac CR/ER/XR
□ Pennsaid
□ Zipsor
Sulindac
Indomethacin
□ Fenoprofen
□ Piroxicam
□ Zorvolex
Ketoprofen
□ Flector Patch
□ Ponstel
□ Other (specify):
Strength:
Dosage Instructions:
Quantity:
Days Supply:
Diagnosis:
Page 1 of 2

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