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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage109DateAugust 1, 2013Product√ IndicatesPA RequiredMAC per Tablet,ML or GMPediatric oral electrolyte solution 0.0054Phos-Nak powder concentrate √ 0.3880Poly-Iron 150 mg capsules √ 0.2750Poly-Vi-Sol drops √ 0.1604Poly-Vi-Sol w/iron drops √ 0.1604Progesterone powder 2.0231Progesterone micronized powder 1.0841Pyridoxine 100 mg tablets √ 0.0399Pyridoxine 25 mg tablets √ 0.0697Pyridoxine 50 mg tablets √ 0.1050Slow-mag tablets √ 0.1708Sodium bicarbonate 325 mg tablets √ 0.0116Sodium bicarbonate 650 mg tablets √ 0.0134Sodium chloride injection 0.9% 0.0030Sodium chloride solution 0.9% for inhalation 0.0451Thera-M enhanced tablets √ 0.0538Tri-Vi-Sol drops √ 0.1887Tri-Vi-Sol w/iron drops √ 0.1400Vitamin A 10000 IU capsules √ 0.0215Vitamin B-1 100 mg tablets √ 0.0425Vitamin B-1 50 mg tablets √ 0.0217Vitamin B-12 1000 mcg CR tablets √ 0.0998Vitamin B-12 1000 mcg tablets √ 0.0541Vitamin C 500 mg chewable tablets √ 0.0547Vitamin C 500 mg tablets √ 0.0447Vitamin C 1000 mg tablets √ 0.0699Vitamin D 400 unit drops √ 0.1440Vitamin D 1000 unit tablets √ 0.0499Vitamin D 2000 unit tablets √ 0.0349Vitamin D 400 unit tablets √ 0.0220Vitamin E 400 unit capsules √ 0.08725. Date of Birth VerificationPoint of sale edits for the exact date of birth from the eligibility file for IowaMedicaid members. Field # 304-C4 (Date of Birth) on The National Counselfor Prescription Drug Programs (NCPDP) Payer Sheet is mandatory. TheNCPDP rejection message will state “09-Missing/Invalid Date of Birth.”Claims should be resubmitted with the correct date of birth for the member.