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

More documents

Recommendations

Info

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage107DateAugust 1, 2013MedicationStadol nasal spray 10mg/ml (butorphanol)Synagis 50 mg(palivizumab)Correct Unitfor BillingMl (Submit indecimal format; donot round)Ml (Submit indecimal format; donot round)Days’Quantity SupplyVaries; claims Variesshould be divisibleby 2.5 ml0.5 ml 30Synagis 100 mgMl 1 ml 30(palivizumab)Ventolin HFA (albuterol) Grams 18 grams 30Xopenex HFA(levalbuterol)3. Compounded PrescriptionsGramsVaries; claimsshould be divisibleby 15 gramsVariesIowa Medicaid will process claims for compounded prescriptions in the NCPDPD.Ø format using the multiple ingredient functionality. All applicable edits,including Preferred Drug List (PDL) rules, apply to each NDC submitted.Providers must submit the NDCs for the active ingredients dispensed tocreate the compound.A dispensing fee will be added to the claim when a drug within the compoundis reimbursed at EAC or State MAC price. There will be no additional fee paidto prepare the compounded prescription. Providers need to submit thequantity of the active ingredients used in the compound for reimbursement,not the quantity of the total amount of the compound made.4. Coverage of Non-Drug ProductsProducts not approved as prescription drugs by the Food and DrugAdministration do not meet the definition of “covered outpatient drugs” andcannot be covered by Medicaid pharmacy program. Coverage of theseproducts is allowed in other coverage areas, such as medical supplies.Medicaid will continue to cover certain non-drug products as listed below.Pharmacies shall continue to provide these products and bill Medicaid throughthe point of sale system. Prior authorizations (PA) will be submitted throughthe Pharmacy PA system.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage108DateAugust 1, 2013Product√ IndicatesPA RequiredMAC per Tablet,ML or GMAmmonium lactate lotion 12% 0.0933AquADEKs capsules √ 0.1489AquADEKs tabs √ 0.5306AquADEKs solution √ 0.3678Bacterostatic sodium chloride injection 0.9% 0.0459Bacterostatic water for injection 0.0240Bacterostatic parabens water for injection 0.0420Calcionate syrup 1.8 gm/5 √ 0.0417Calcium carbonate 500 mg chewable tablets √ 0.0205Calcium carbonate 750 mg chewable tablets √ 0.0381Calcium carbonate 1000 mg chewable tablets √ 0.0469Calcium carbonate 1250 mg chewable tablets √ 0.1026Calcium carbonate 1250 mg/5 ml suspension √ 0.0579Calcium carbonate 600 mg tablets √ 0.0440Calcium carbonate-vitamin D 500 mg/200 unit √ 0.0468Calcium carbonate-vitamin D 600 mg/200 unit tablets √ 0.0294Calcium carbonate-vitamin D 600/400 unit tablets √ 0.0516Calcium gluconate 650 mg tablets √ 0.0152Calcium lactate 650 mg tablets √ 0.0232Calvite P&D tablets √ 0.1846Cerovite Jr chewable tablets √ 0.0551Cerovite liquid √ 0.0228Cholecalciferol 400 Unit tablets √ 0.0249Epoprostenolol diluents (Flolan) 0.5 mg 12.72Epoprostenolol diluents (Flolan) 1.5 mg 40.04Ferrex 150 capsules plus √ 1.2769Ferrous fumarate 325 mg tablets 0.0181Ferrous gluconate 325 mg tablets 0.0462Ferrous sulfate 75 mg/0.6 ml drops 0.0388Ferrous sulfate 75 mg/ml drops 0.1629Ferrous sulfate 220 mg/5 ml elixir 0.0127Ferrous sulfate 325 mg tablets 0.0246Mag-delay tablets √ 0.1198Magnesium oxide 400 mg tablets √ 0.0852Magonate 1000 mg/5 ml liquid √ 0.0267Maximum D3 capsules √ 0.9900Metronidazole powder 1.5775Multiple vitamins tablets √ 0.0261Nephro-Vite tablets √ 0.1107Niacin 50 mg tablets 0.0185Niacin 100 mg tablets 0.0239Niacin 250 mg tablets 0.0369Niacin 500 mg tablets 0.0372
Page 1 and 2:
Prescribed DrugsProvider Manual
Page 3 and 4:
III. Provider-Specific Policies
Page 5 and 6:
IowaDepartmentof HumanServicesProvi
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64: IowaDepartmentof HumanServicesProvi
Page 113: IowaDepartmentof HumanServicesProvi
show all

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

Create successful ePaper yourself

Delete template?

Save as template?