Pharmacy
Iowa Total Care adheres to the State of Iowa Preferred Drug List (PDL) to determine medications that are covered under the Iowa Total Care Pharmacy Benefit, as well as which medications may require Prior Authorization (PA).
Some members may have copayment or cost share when utilizing their prescription benefits. Please refer to the Iowa Total Care Member ID card for information or call Iowa Total Care at 1-833-404-1061.
- Age Edit Override – Codeine or Tramadol (PDF)
- Alpha1 Proteinase Inhibitors (PDF)
- Alpha2 Agonist, Extended Release (PDF)
- Amylino Mimetic (Symlin®) (PDF)
- Antidepressants (PDF)
- Anti-Diabetics Non-Insulin Agents (PDF)
- Antiemetic-5HT3 Receptor Antagonists/Substance P Neurokinin Products (PDF)
- Antifungal Drugs - Oral / Injectable (PDF)
- Antihistamines (PDF)
- Apremilast-Otezla (PDF)
- Aripiprazole (Abilify MyCite) Tablets with Sensor (PDF)
- Becaplermin (Regranex®) (PDF)
- Benzodiazepines (PDF)
- Binge Eating Disorder Agents (PDF)
- Biologicals for Ankylosing Spondylitis (PDF)
- Biologicals for Arthritis (PDF)
- Biologicals for Hidradenitis Suppurativa (PDF)
- Biologicals for Inflammatory Bowel Disease (PDF)
- Biologicals for Plaque Psoriasis (PDF)
- Calcifediol (Rayaldee) (PDF)
- Cannabidiol (PDF)
- CGRP Inhibitors (PDF)
- Cholic Acid (Cholbam®) (PDF)
- CNS Stimulants and Atomoxetine (PDF)
- Concurrent IM/PO Antipsychotic Utilization (PDF)
- Crisaborole (Eucrisa) (PDF)
- Cystic Fibrosis Agents: Oral (PDF)
- Dalfampridine (Ampyra) (PDF)
- Deferasirox (PDF)
- Deflazacort (Emflaza) (PDF)
- Dextromethorphan and Quinidine (Nuedexta) (PDF)
- Direct Oral Anticoagulants (PDF)
- Dupilumab (Dupixent) (PDF)
- Duplicate Therapy Edit Override (PDF)
- Eluxadoline (Viberzi™) (PDF)
- Erythropoiesis Stimulating Agents (PDF)
- Eteplirsen (Exondys 51) (PDF)
- Extended Release Formulations (PDF)
- Febuxostat (Uloric®) (PDF)
- Fentanyl, Short Acting Products (PDF)
- Fifteen Day Initial Prescription Supply Override (PDF)
- GLP-1 Agonist/Basal Insulin Combinations (PDF)
- Granulocyte Colony Stimulating Factor (PDF)
- Growth Hormones (PDF)
- Hemotopietics/Chronic ITP (PDF)
- Hepatitis C Treatments (PDF)
- Addendum Post Hepatitis C Treatment Information Sustained Virologic Response (SVR) Reporting (PDF)
- High Dose Opioids (PDF)
- Idiopathic Pulmonary Fibrosis (PDF)
- Isotretinoin (Oral) (PDF)
- Janus Kinase (JAK) Inhibitors (PDF)
- IL-5 Antagonists (PDF)
- Ketorolac Tromethamine (PDF)
- Mifepristone (Korlym®) (PDF)
- Lesinurad (Zurampic) (PDF)
- Letermovir (Prevymis™) (PDF)
- Lidocaine Patch (PDF)
- Linezolid (Zyvox®) (PDF)
- Long-acting Opioids (PDF)
- Lumacaftor/Ivacaftor (Orkambi™) (PDF)
- Lupron Depot - Adult (PDF)
- Lupron Depot - Pediatric (PDF)
- Methotrexate Injection (PDF)
- Miscellaneous (PDF)
- Modified Formulations (PDF)
- Multiple Sclerosis Agents: Oral (PDF)
- Muscle Relaxants (PDF)
- Narcan (Naloxone) Nasal Spray (PDF)
- Narcotic Agonist / Antagonist Nasal Sprays (PDF)
- Nebivolol (Bystolic®) (PDF)
- New-to-Market Drugs (PDF)
- Nocturnal Polyuria Treatments (PDF)
- Non-Parenteral Vasopressin Derivatives of Posterior Pituitary Hormone Products (PDF)
- Non-Preferred Drug (PDF)
- Nonsteroidal Anti-Inflammatory Drugs (PDF)
- Ospemifene (Osphena) (PDF)
- Oral Constipation Agents (PDF)
- Oral Immunotherapy (PDF)
- Oral MS Agents (PDF)
- Elagolix (Orilissa) (PDF)
- Palivizumab (Synagis®) (PDF)
- PCSK9 Inhibitors (PDF)
- Potassium Binders (PDF)
- Proton Pump Inhibitors (PDF)
- Pulmonary Arterial Hypertension Agents (PDF)
- Quantity Limit Override (PDF)
- Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)
- Rifaximin (Xifaxan®) (PDF)
- Roflumilast (Daliresp™) (PDF)
- Sapropterin Dihydrochloride (Kuvan) (PDF)
- Sedative/Hypnotics-Non-Benzodiazepine (PDF)
- Selected Brand Name Drugs (PDF)
- Select Oncology Agents (PDF)
- Serotonin 5-HT1 Receptor Agonists (PDF)
- Short Acting Opioids (PDF)
- Sodium Oxybate (Xyrem®) (PDF)
- Tasimelteon (Hetlioz®) (PDF)
- Testosterone Products (PDF)
- Tezacaftor/Ivacaftor (Symdeko™) (PDF)
- Topical Acne and Rosacea Products (PDF)
- Topical Antifungals for Onychomycosis (PDF)
- Topical Corticosteriods (PDF)
- Topical Immunomodulators (PDF)
- Valsatan/Sacubitril (Entresto) (PDF)
- Vitamins & Minerals (PDF)
- Vesicular Monoamine Transporter (VMAT) 2 Inhibitors (PDF)
- Vorapaxar (Zontivity™) (PDF)
- Voxelotor (Oxbryta) (PDF)
- Miconazole-Zinc Oxide-White Petrolatum (Vusion) Ointment (PDF)
Iowa Total Care works with Envolve Pharmacy Solutions to administer pharmacy benefits, including the Prior Authorization process.
Prior Authorization Fax: 1-877-386-4695
Clinical Hours: Monday – Friday 10 a.m. - 8 p.m. (CST)
To find a pharmacy that is in the Iowa Total Care network, you can use the Find a Provider tool