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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage110DateAugust 1, 20136. Override CodesA 72-hour emergency supply of medication may be dispensed using priorauthorization type code “1” as a point of sale override. The provision for a72-hour supply can be used in an emergency situation only one time permember, per drug.A seven-day override of the prior authorization requirement will be allowedwhile the prescriber is requesting prior authorization for certain mental healthdrugs. The override applies to drugs that are deemed to have a significantvariation in therapeutic or side effect profile from other drugs in the sametherapeutic class. See the Preferred Drug List at: www.iowamedicaidpdl.comThe pharmacy may use a prior authorization type code “7” as a point of saleoverride for applicable mental health drugs. The seven-day provision can beused only one time per member, per NDC, per 30 days.7. Proper Reporting of NDCsThe Iowa Medicaid Program can cover only drugs from manufacturers whohave signed national Medicaid drug rebate agreements with the Centers forMedicare and Medicaid Services (CMS). Drug companies sign the agreementsfor specific drug manufacturer codes called national drug codes (NDC).Since rebates are determined by Iowa Medicaid’s utilization data, it isimperative that pharmacies and providers bill Iowa Medicaid using the correctNDC number of the drug actually dispensed or administered.If a provider is dispensing or administering one drug and billing for an NDCdifferent from the drug being dispensed or administered, it is consideredfraud, which can result in claims being recouped, sanctions, and terminationof provider agreements. The Program Integrity Unit will be monitoring forthis in their reviews.