Provider Notice issued 10/25/01

 Prior Approval Information

Effective with dates of service on or after November 15, 2001, the Department will make the following changes to its prior approval requirements.

Santyl Ointment

The following prior approval criteria will be used to process requests for Santyl ointment. he following prior approval criteria wihe following prior approval criteria will be used to process requests for Santyl ointment. he following prior approval criteria will be used to process requests for Santyl ointment.

The only indication for Santyl ointment is debriding chronic dermal ulcers or burns.

A course of therapy is limited to a maximum of 120 grams. Debridement is usually completed within 10 to 14 days.

If more than two courses of therapy are requested for the same lesion, information is required from the prescribing physician that includes documentation of: the size of the wound, the amount of tissue remaining to be debrided, the extent of granulation tissue present, and whether or not the wound is infected (contamination with pathogenic organisms is considered infection).

Bactroban 

Bactroban cream and ointment will require prior approval when prescribed for patients age 21 or older. All requests for prior approval must be accompanied by medical information documenting the patient=s diagnosis and the dose and schedule of the prescribed medication. The Department will not pay for more that 30 grams of either Bactroban cream or Bactroban ointment per patient during any six month period, regardless of the patient=s age, unless requests are supported with medical information from the prescribing physician indicating the medical necessity. The acceptable indications for prescribing Bactroban cream or ointment are Impetigo or other superficial, non-cellulitic wound infections, such as infected superficial abrasions. A course of treatment is restricted to a maximum of two weeks. In most instances, the treatment should not exceed ten days.

Lidoderm Patches 

Lidoderm patches currently require prior approval. The only approved indication is for Post Herpetic Neuralgia. Requests must be supported by information from the prescribing physician that confirms the diagnosis. It is recommended that consideration be given to the use of Lidocaine cream or ointment or Lidocaine Viscous, which are available without prior approval, for patients who may benefit from use of a topicidoderm patches currently require prior approval. The only approved indication is for Post Herpetic Neuralgia. Requests must be supported by information from the prescribing physician that confirms the diagnosis. It is recommended that consideration be given to the use of Lidocaine cream or ointment or Lidocaine Viscous, which are available without prior approval, for patients who may benefit from use of a topical anesthetic agent. idoderm patches currently require prior approval. The only approved indication is for Post Herpetic Neuralgia. Requests must be supported by information from the prescribing physician that confirms the diagnosis. It is recommended that consideration be given to the use of Lidocaine cream or ointment or Lidocaine Viscous, which are available without prior approval, for patients who may benefit from use of a topicidoderm patches currently require prior approval. The only approved indication is for Post Herpetic Neuralgia. Requests must be supported by information from the prescribing physician that confirms the diagnosis. It is recommended that consideration be given to the use of Lidocaine cream or ointment or Lidocaine Viscous, which are available without prior approval, for patients who may benefit from use of a topical anesthetic agent.

Once Daily Dosing

http://www.state.il.us/dpa/html/pharmacies.htm

To view or print a list of the commonly dispensed medications identifying the maximum amounts currently included in the Department’s Prospective DUR editing, click on the link "Table of Maximum Daily Doses."

Pharmacies must use the exact National Drug Code (NDC) number of the product dispensed when submitting a claim to the Department for reimbursement consideration. Final confirmation of product coverage and Medicaid participant eligibility status are available to all participating pharmacies through the Department’s electronic point-of-sale claims processing system.

If you have questions concerning this notice, please contact the Bureau of Comprehensive Health Services at (217) 782-5565 and ask to speak to a Pharmacy Unit billing representative.

Matt Powers, Administrator

Division of Medical Programs