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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage4DateAugust 1, 2013Nonrecommended drug means a drug placed on a voluntary list (designedto inform prescribers of cost-effective alternatives) that does not require aprior authorization but if used will be more costly to the Medicaid program. Anonrecommended drug is designated “NR” on the recommended drug list.Pharmaceutical and Therapeutics (P&T) Committee means a committeeof nine members appointed by the Governor that is charged with developingand providing ongoing review of the Preferred Drug List pursuant to IowaCode section 249A.20A.Preferred drug means a drug on the Preferred Drug List that providesmedical equivalency to the Medicaid member in a cost-effective manner (byvirtue of OBRA ’90 and Supplemental Rebate) and does not require a priorauthorization. A preferred drug is designated “P” on the Preferred Drug List.Preferred Drug List (PDL) means a list comprised of drugs recommendedto the Iowa Department of Human Services by the Iowa MedicaidPharmaceutical and Therapeutics Committee that have been identified asbeing therapeutically equivalent within a drug class and that provide costbenefit to the Medicaid program.Preferred drug with conditions means a drug has “preferred” agents butbefore getting the drug a patient must meet medical criteria and guidelinesthat coincide with current prior authorization guidelines. A preferred drugwith conditions is designated “P” on the Preferred Drug List and has a numberin the comments column to indicate a prior authorization is required, asdefined on the first page of the Preferred Drug List (PDL).Prior authorization (PA) means obtaining approval for a drug before thedrug is provided to a member, as a precondition for provider reimbursement.Prior authorization is requested at the prescriber level and is a prescriber faxonlysystem using the forms provided by the Iowa Medicaid Enterprise.Professional dispensing fee means payment provided for the costsincurred by a pharmacy to dispense a drug. The fee reflects the pharmacist’sprofessional services and costs associated with ensuring that possession ofthe appropriate covered outpatient drug is transferred to a Medicaid member.Prospective drug utilization review (Pro-DUR) means a process in whicha request for a drug product for a particular patient is screened for potentialdrug therapy problems before the product is dispensed.