Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.2 - Prescribed Outpatient Drugs

Current through Register Vol. 47, No. 3, July 24, 2024
Payment will be made for "covered outpatient drugs" as
				  defined in
				  42 U.S.C. Section
				  1396r-8(k)(2)-(4) subject to
				  the conditions and limitations specified in this rule.
(1)
Qualified prescribes
All
				drugs are covered only if prescribed or ordered by an Iowa Medicaid-enrolled
				practitioner licensed or registered to prescribe as specified in Iowa Code
				section
				155A.3(38).
(2)
Prescription required.
As a condition of payment for all drugs, including "nonprescription" or
				"over-the-counter" drugs that may otherwise be dispensed without a prescription
				or drug order, a prescription or drug order shall be transmitted as specified
				in Iowa Code sections
				124.308, 155A.3 and
				155A.27
				by the practitioner to the pharmacy, subject to the provisions of Iowa Code
				section
				155A.29
				regarding refills. All prescriptions or drug orders shall be available for
				audit by the department.
(3)
Qualified source.
All drugs are covered only if marketed by
				manufacturers that have signed a Medicaid rebate agreement with the Secretary
				of Health and Human Services in accordance with
				Public
				Law 101-508 (Omnibus Budget Reconciliation Act of
				1990).
(4)
Prescription
				drugs.
Drugs that may be dispensed only upon a prescription are
				covered subject to the following limitations.
a. Prior authorization is required as
				specified in the preferred drug list published by the department pursuant to
				Iowa Code section
				249A.20A.
(1) For any drug requiring prior
				authorization, reimbursement will be made for a 72-hour or three-day supply
				dispensed in an emergency when a prior authorization request cannot be
				submitted.
(2) Unless the
				manufacturer or labeler of a mental health prescription drug that has a
				significant variation in therapeutic or side effect profile from other drugs in
				the same therapeutic class enters into a contract to provide the state with a
				supplemental rebate, the drug may be placed on the preferred drug list as
				nonpreferred, with prior authorization required. However, prior authorization
				shall not be required for such a drug for a member whose regimen on the drug
				was established before January 1, 2011, as verified by documented pharmacy
				claims.
(3) For mental health
				prescription drugs requiring prior authorization that have a significant
				variation in therapeutic or side effect profile from other drugs in the same
				therapeutic class, reimbursement will be made for up to a seven-day supply
				pending prior authorization. A request for prior authorization shall be deemed
				approved if the prescriber:
1. Has on file
				with the department current contact information, including a current fax
				number, and a signed Form 470-4914, Fax Confidentiality Certificate,
				and
2. Does not receive a notice of
				approval or disapproval within 48 hours of a request for prior
				authorization.
(4) Prior
				authorization for medication-assisted treatment shall be governed pursuant to
				subrule 78.28(2).