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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.

For pharmacists only: For point-of-sale billing issues, please call 1-833-750-4405.

For any additional pharmacy questions or if you are experiencing difficulties, please email us.

Submit your prior authorization (PA) requests electronically through CoverMyMeds.

Electronic prior authorization (ePA) automates the PA process, making it simpler to complete PA requests. The ePA process is HIPAA-compliant and enables faster determinations.

For select drugs and plans, CoverMyMeds may issue immediate approval of your request and update your patient record to allow immediate claim adjudication.

To find a pharmacy that is in the Iowa Total Care network, you can use the Find a Provider tool.

Iowa Total Care members will have an option to receive a 90-day supply of certain maintenance medications. This encourages members to maintain healthy behaviors and decreases barriers to access. Please consider prescribing accordingly for members that would benefit from this allowance.

For the current list of 90-day supply allowance prescriptions, visit the Iowa Medicaid PDL page.

To contract as a pharmacy with Iowa Total Care, follow the steps below:

For Point of Sale (POS) billing, join the Express Scripts pharmacy network:

1. Visit the Express Scripts Provider website.

2. Select Create an Account Now! or log in.

3. Select Apply to Become a Network Provider.

a. Complete the provider application.

b. Owner or authorized signer: sign provider application.

c. Complete pharmacy disclosure.

d. Owner or authorized signer: sign the pharmacy disclosure.

e. If you are joining a Pharmacy Services Administration Organization (PSAO) (depending on how you answer), an agreement with the PSAO will need to be signed.

f. If you are joining as part of a PSAO, send your documentation to that PSAO. If you are joining independently, send the documents directly to the Express Scripts Network Compliance mailbox.

g. This mailbox is where independent pharmacies may reach out with general questions, which may include questions about:

-  New applications/process

- Change of ownership application/process.

- Re-credentialing applications/process.

- Appeals for application denials.Specific rejections for independently contracted pharmacies (see below).

- How to change or set up a PSAO or Group Purchasing Organization (GPO) affiliation.

- How to update pharmacy demographics.

To setup Electronic Funds Transfer (EFT), follow the steps below:

For Durable Medical Equipment (DME) and Pharmacy/Pharmacist Medical Billing:

1.  Visit the Iowa Total Care Become a Provider webpage.

2. Click on the Contract Request Form link.

3. Contract Request Form completion:

a. Under Type of Contract Request, select New Contract.

b. In the Entity NPI field, enter the pharmacy NPI.

c. In the Provider Type section, select Ancillary or Hospital Based Practitioners.

d. Complete the form in its entirety and click Submit.

4. Once the form has been submitted online, send an email notification to Iowa Total Care’s Network Management team. Iowa Total Care will reach out for additional information if needed.

The pharmacy will receive final confirmation of enrollment via email.

How to complete Point of Sale (POS) pharmacy billing:

Iowa Total Care currently uses Express Scripts as the Pharmacy Benefit Manager (PBM) for pharmacy billing. When billing, you will need to provide:

  • BIN (Bank Identification Number): 003858
  • RX PCN: MA
  • RxGroup: 2EGA

You can find applicable medications on the Iowa Medicaid Preferred Drug List (PDL).

How to complete medical billing:

For vaccines:

  • Complete administration and vaccine code together on the same claim, and NDC (National Drug Code) must be one that is allowed in the system, generally what is on the vial instead of the one on the box.

For all diabetic test strips, lancets, Continuous Glucose Monitors (CGM):

a. Include the New durable medical equipment purchase (NU) modifier when billing for these items.

b.  Prior authorization needed:

- A4239 - supply allowance for non-implanted continuous glucose monitor (1 unit=1 month supply, may request up to 6 months/6 units).

- E2103 - Non-adjunctive, non-implanted continuous monitor or Receiver (1/year).

- A4238 - supply allowance for adjunctive continuous glucose monitor.