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

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage2DateAugust 1, 2013Covered entity means a provider that meets eligibility criteria forparticipating in the 340B Program as set forth in Section 340B(a)(4) of thePublic Health Service Act.DESI drugs means drug products identified by the federal Food and DrugAdministration, in the Drug Efficacy Study Implementation Program, aslacking substantial evidence of effectiveness.Drug rebates means payments provided by pharmaceutical manufacturersto state Medicaid programs under the terms of the manufacturers’agreements with the Department of Health and Human Services or with theindividual state.Drug utilization review (DUR) means a quality review of coveredoutpatient drugs that assures that prescriptions are appropriate, medicallynecessary, and not likely to result in adverse medical outcomes.Drug Utilization Review Commission means a quality assurance body ofnine members that seeks to improve the quality of pharmacy services andensure rational, cost-effective medication therapy for Medicaid members inIowa. The web site for the Commission is www.iadur.org.Equivalent products means those products that meet therapeuticequivalence standards as published in the federal Food and DrugAdministration document, Approved Prescription Drug Products withTherapeutic Equivalence Evaluations.Federal upper limit (FUL) means the maximum allowable reimbursementset by the Centers for Medicare and Medicaid Services for a multiple-sourcedrug. The list is available at the federal pharmacy reimbursement web site:http://www.cms.hhs.gov/Reimbursement/Grandfather clause means a clause creating an exemption based onpreviously existing circumstances. The Pharmaceutical and TherapeuticsCommittee considered select therapeutic classes for grandfathering existingdrug regimens. For claims processing, “drug history” means the most recent90-day period. If a patient has a history with a specific drug within theseclasses, the prescriber is not required to obtain prior authorization even if thedrug has a nonpreferred status on the Preferred Drug List.Legend drugs are drugs that bear the federal caution: “Federal LawProhibits Dispensing a Drug Without a Prescription.”