Prescribed Drugs Provider Manual - Iowa Department of Human ...
Prescribed Drugs Provider Manual - Iowa Department of Human ...
Prescribed Drugs Provider Manual - Iowa Department of Human ...
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<strong>Iowa</strong><strong>Department</strong><strong>of</strong> <strong>Human</strong>Services<strong>Provider</strong> and Chapter<strong>Prescribed</strong> <strong>Drugs</strong>Chapter III. <strong>Provider</strong>-Specific PoliciesPage103DateAugust 1, 2013FIELD NAME/DESCRIPTIONINSTRUCTIONSCOMPOUND64 – DOSAGE FORMDESCRIPTION CODE65 – DISPENSING UNIT FORMINDICATOR66 – ROUTE OFADMINISTRATION67 – INGREDIENT COMPONENTCOUNTMANDATORY.MANDATORY.OPTIONAL.MANDATORY.68 – PRODUCT NAME REQUIRED. Submit for each compound component.69 – PRODUCT ID REQUIRED. Submit for each compound component.70 – PRODUCT ID QUALIFIER REQUIRED. Submit for each compound component.71 – INGREDIENT QTY REQUIRED. Submit for each compound component.72 – INGREDIENT DRUG COST OPTIONAL. Submit for each compound component.73 – BASIS OF COST OPTIONAL. Submit for each compound component.PRICING74 – USUAL & CUSTOMARYCHARGE75 – BASIS OF COSTDETERMINATION76 – INGREDIENT COSTSUBMITTEDREQUIRED. Enter the usual and customary charge.CONDITIONAL. Enter code “09” to indicate unit dosedrug. Otherwise, leave blank.REQUIRED. Enter the pharmacy’s submittedproduct component cost <strong>of</strong> the dispensedprescription. Amount also included in the grossamount due.340B pricing submitted in this field whenapplicable.77 – DISPENSING FEESUBMITTEDREQUIRED. Enter the pharmacy’s usual andcustomary dispensing fee. Enter zeros if nodispensing fee is charged for the prescription.