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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage60DateAugust 1, 201362. Quantity Limit Overridea. Initial 15-Day LimitDrugs that have been identified with high side effect profiles, highdiscontinuations rates, or frequent dose adjustments are limited to a15-day initial supply. The initial prescription supply limit ensures costeffectiveness without waste of unused medications.These drugs are identified on the Fifteen Day Initial Prescription SupplyLimit list located on the website www.iowamedicaidpdl.com under thePreferred Drug Lists tab and the Billing/Quantity Limits tab.To request authorization for an initial supply longer than 15 days,submit form 470-5038, Request for Fifteen Day Initial PrescriptionSupply Override, for consideration. Click here for a sample of the form.The form is located at www.iowamedicaidpdl.com under PA Forms.Documentation of medical necessity, excluding patient convenience, isrequired for consideration of the 15-day initial supply override.b. Monthly LimitsDesignated drugs have specific quantity limitations. These drugs areidentified on the Iowa Medicaid Quantity Limit Chart posted on thewebsite www.iowamedicaidpdl.com under the Billing/Quantity Limits tab.Medication doses that use multiple, lower-strength tablets should beconsolidated to the higher-strength tablet. Quantity limits based on thecompendia are also enforced. Please view the current list atwww.iowamedicaidpdl.com under Quantity Limits.Prior authorization is required if there is a reason the higher tabletstrength cannot be used or a medical rationale for use of higher thanrecommended dosing.Providers should submit a Prior Authorization request for overrideconsideration. Use form 470-4556, Request for Prior Authorization:Request for Quantity Limit Override, to request prior authorization.Click here to see a sample of the form. The form is located atwww.iowamedicaidpdl.com under PA Forms.