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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsPage3DateAugust 1, 2013Page47. Linezolid (Zyvox ® ) ............................................................................. 4948. Mifepristone (Korlym ® )....................................................................... 5049. Modified Formulations ........................................................................ 5050. Muscle Relaxants ............................................................................... 5151. Narcotic Agonist-Antagonist Nasal Sprays .............................................. 5152. Nebivolol (Bystolic ® ) .......................................................................... 5253. Nicotine Replacement Products ............................................................ 5254. Nonparenteral Vasopressin Derivatives of Posterior Pituitary HormoneProducts ........................................................................................... 5355. Nonpreferred Drugs ........................................................................... 5456. Nonsteroidal Anti-Inflammatory Drugs .................................................. 5457. Omalizumab (Xolair ® ) ........................................................................ 5558. Oxycodone ER/CR (OxyContin ® ) .......................................................... 5659. Palivizumab (Synagis ® ) ...................................................................... 5660. Proton Pump Inhibitors ....................................................................... 5861. Pulmonary Arterial Hypertension Agents ................................................ 5962. Quantity Limit Override ...................................................................... 60a. Initial 15-Day Limit ..................................................................... 60b. Monthly Limits ............................................................................ 6063. Roflumilast (Daliresp) ...................................................................... 8164. Sedative/Hypnotics-Non-Benzodiazepine ............................................... 8265. Selected Brand-Name Drugs ................................................................ 8266. Serotonin 5-HT1 Receptor Agonists ...................................................... 8367. Short-Acting Narcotics ........................................................................ 8468. Smoking Cessation Therapy-Oral ......................................................... 8469. Sodium Oxybate (Xyrem ® ).................................................................. 8570. Thrombopoietin Receptor Agonists ....................................................... 8571. Topical Retinoids ............................................................................... 8672. Vemurafenib (Zelboraf).................................................................... 8773. Vilazodone (Viibryd ) ......................................................................... 8774. Vitamins, Minerals and Multiple Vitamins ............................................... 8875. Vusion Ointment ............................................................................. 88D. BASIS OF PAYMENT FOR DRUGS AND SUPPLIES ............................................ 891. Reimbursement Effective February 1, 2013 ........................................... 90a. Generic and Nonprescription Drugs ............................................... 90b. Brand-Name Drugs ..................................................................... 902. Drugs Subject to Federal Upper Limit (FUL) ........................................... 90a. FUL Development ....................................................................... 90b. Reimbursement for FUL Drugs ...................................................... 913. Reimbursement for Unit-Dose Packaging ............................................... 914. Reimbursement for Vaccinations .......................................................... 92
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsPage4DateAugust 1, 2013PageE. BILLING SYSTEM ...................................................................................... 941. Point of Sale Claim Submission ............................................................ 94a. Claims Rejected Due to Other Insurance Coverage .......................... 95b. Correction of Insurance Information .............................................. 962. Claiming Payment for Retroactively Eligible Member ............................... 963. Claim Attachment Control, Form 470-3969 ............................................ 974. Paper Claim Submission ...................................................................... 97F. EDITS AND SPECIAL BILLING INFORMATION .............................................. 1051. Claims for Deceased Members ........................................................... 1052. Common Billing Errors ...................................................................... 1053. Compounded Prescriptions ................................................................ 1074. Coverage of Non-Drug Products ......................................................... 1075. Date of Birth Verification ................................................................... 1096. Override Codes ................................................................................ 1107. Proper Reporting of NDCs ................................................................. 1108. Prospective Drug Utilization Review (Pro-DUR)..................................... 111a. Age Edits ................................................................................. 113b. Cost Effectiveness Edit .............................................................. 115c. Dosage Form Edits .................................................................... 116d. Excessive Days Supply .............................................................. 116e. High-Dollar Claims .................................................................... 116f. Refill Too Soon ......................................................................... 117g. Step Therapy Edits.................................................................... 117h. Tablet Splitting ......................................................................... 117i. Therapeutic Duplication ............................................................. 1189. Status Change for Preferred Brand Name Drugs ................................... 11810. Travel or Vacation Supplies of Medication ............................................ 11811. 340B Drug Pricing Program ............................................................... 119a. Covered Entity (CE) .................................................................. 119b. Iowa Medicaid Billing/Reimbursement for CE Outpatient In-HousePharmacy or Contracted Pharmacy .............................................. 12012. Interpreter Services ......................................................................... 120a. Documentation of the Service ..................................................... 121b. Qualifications ........................................................................... 121G. REMITTANCE ADVICE AND FIELD DESCRIPTIONS ........................................ 1221. Remittance Advice Explanation .......................................................... 1222. Remittance Advice Field Descriptions .................................................. 123
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