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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage9DateAugust 1, 2013♦ Proper storage♦ Prescription refill information, including the approximate date whenrefill will be allowed (generally, 90% of the prescription is used)♦ Actions to be taken in the event of a missed dose♦ Comments relevant to the patient’s drug therapy, including any otherinformation peculiar to the specific patient or drugPatient counseling is required in accordance with federal law at 42 USCSection 1396r(g)(2)(A)(ii)(l) and state rules at 657 Iowa AdministrativeCode 8.20(1)-(2).d. Reason for DenialThe pharmacist should explain the reason for any denial of a requesteddrug or item to the member or caregiver. For example, denial could bedue to one of the following:♦ Noncovered drug or item. Explain why the drug or item is notcovered and suggest alternatives to the member, caregiver, orpractitioner.♦ Prior authorization requirement. Explain the prior authorizationprocess and requirements to the member or caregiver.When a patient presents a prescription for nonpreferred drug at apharmacy and it is denied, contact the prescriber and ask if theprescriber wishes to choose a preferred drug.• If the prescriber wishes to change to a preferred drug, theprescriber may dictate the new prescription order.• If the prescriber views that the nonpreferred drug is medicallynecessary, the prescriber must obtain prior authorization.♦ Refill too soon. Inform the member or caregiver of an approximatedate the prescription can be refilled (after 90% of the previoussupply is used).In special circumstances, such as a change in dose, travel, or lost,stolen or destroyed medication, that result in an early refill, contactthe IME Pharmacy Point of Sale (POS) Unit at (515) 256-4608 (localcalls) or 877-463-7671 with the information. This information will bereviewed to determine if an override can be given to allow payment.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage10DateAugust 1, 2013♦ Plan limits exceeded. Refer to the limits list posted on the website, www.iowamedicaidpdl.com, under “Billing/Quantity Limits.” Thenumber of doses should be reduced to meet the quantity limit.If there are special circumstances where adherence to the quantitylimit is not possible, the prescriber should complete form 470-4556,Quantity Limit Override, or form 470-5038, Request for Fifteen DayInitial Prescription Supply Override, and fax it to 1-800-574-2515.The clinical staff will review the information submitted and determineif an override can be given to allow payment.If the member or caregiver is not satisfied with the explanation of thereason for a denial, refer the person to the member’s DHS worker forassistance in filing an appeal or requesting an exception to policy.Appeal and exception requests may be filed on line through thefollowing web site: http://www.dhs.state.ia.us/dhs/appeals/.5. Drug Use ReviewThe drug use review (DUR) process was established to fulfill a federalrequirement established by the federal Omnibus Budget Reconciliation Act of1990. Iowa Medicaid has implemented both of the required DUR types:♦ Prospective drug utilization review occurs when the pharmacist doesthe review of patient drug therapy at the point of sale. See PharmacistResponsibilities.♦ Retrospective drug utilization review occurs when the review takesplace after the point of sale.The retrospective DUR program provides ongoing periodic examination ofclaims data and other records in order to identify patterns of fraud, abuse,gross overuse, or inappropriate or medically unnecessary care amongphysicians, pharmacists, and members, or associated with specific drugs.
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