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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage111DateAugust 1, 20138. Prospective Drug Utilization Review (Pro-DUR)The goal of Prospective DUR is to identify potential drug therapy concerns toallow the pharmacist to use professional judgment regarding the need forintervention, such as whether or not to contact the prescribing physician.The following prospective DUR edits will cause claims to deny:EditNumber andMessageReason for the Denial* OverrideProvidedAge Edits75 - PRIORAUTHORIZATIONREQUIREDCertain medications arepayable only for specificage groups.PA required.CostEffectiveness75 - PRIORAUTHORIZATIONREQUIREDCertain strengths shouldbe substituted withmore cost-effectivestrengths of the samemedication.PA required.DosageForm75 - PRIORAUTHORIZATIONREQUIREDAdditional text:NONPREFERREDCertain dosage formsshould be substitutedwith more cost-effectivedosage forms of thesame medication.PA required.ExcessiveDaysSupply19 - M/I DAYSSUPPLYAdditional text:EXCEEDS ALLOWABLEDAYS SUPPLYThe supply submitted ismore than 31 days.Request anexception topolicy if there is avalid reason whya supply morethan 31 days isrequired.15-DayInitialPrescriptionSupplyLimit76 - PLAN LIMITSEXCEEDEDThe supply submitted ismore than 15 days onselect drugs.PA required. SeeQuantity LimitOverride.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage112DateAugust 1, 2013EditNumber andMessageReason for the Denial* OverrideProvidedHigh DollarClaims78 - COST EXCEEDSMAXIMUMAdditional text:CLAIM EXCEEDS$10,000.00, PLEASECALL POS HELPDESKAll claims submitted inexcess of $10,000 willbe rejected. Afterverifying that thequantity and days’supply of the claim arecorrect, contact thePharmacy POS HelpDesk. See below.A one-timeoverride will begranted ifquantity anddays’ supply areaccurate andconsistent.Additional medicaldocumentation isrequired forlonger overrides.QuantityLimits76 - PLAN LIMITSEXCEEDEDIf the quantitysubmitted exceeds theestablished quantitylimit.PA required. SeeQuantity LimitOverride.Refill TooSoon79 - REFILL TOOSOONAdditional text:RX NUMBER/FILLDATE/NPI ORIf less than 90% of thepreviously paid claim forthat medication has notbeen used. See RefillToo Soon.If there is achange in dose;lost, stolen ordestroyed drug;or travel.NABP/DATE FOR NEXTFILLStepTherapyEdits75 - PRIORAUTHORIZATIONREQUIREDCertain therapeutic drugclasses are subject tostep therapy edits asdesignated on thePreferred Drug List.PA required.TabletSplitting19 - M/I DAYSSUPPLYAdditional text:MUST SPLIT TABLETSCertain medications thatare scored and easilyhalved should be split tofacilitate more costeffectiveuse of thedrugs.PA required.TherapeuticDuplication88 - DUR REJECTMESSAGEAdditional text:SITUATIONALIf a second claimsubmitted is atherapeutic duplicationof a drug alreadysubmitted andreimbursed.PA required.* Always verify that the quantity and days’ supply on the claim are correct;then for an override contact: Pharmacy POS Help Desk at 877-463-7671 or(515) 256-4608 (local)
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