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  • 470-4119 Request For Prior Authorization Selected Brand Name Drugs - Dhs Iowa

Get 470-4119 Request For Prior Authorization Selected Brand Name Drugs - Dhs Iowa

Iowa Department of Human Services Request for Prior Authorization SELECTED BRAND NAME DRUGS FAX Completed Form To 1 (800) 5742515 Iowa Medicaid MedWatch Form Provider Help Desk 1 (877) 7761567 Revised.

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Related content

Prescribed Drugs - Iowa DHS - Iowa.gov
with the bioequivalent generic drug must be provided. A copy of a completed form 470-4119...
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Prior authorization is required for certain services and supplies. Submission of a prior authorization request form along with all supporting documentation is necessary to obtain these services and/or supplies: Durable Medical Equipment (DME) - Augmentative, Vision, Hearing. DME Rental.

Requests for weight loss are not a covered diagnosis of use and will be denied. Initial authorizations will be approved for six months. Additional PAs will be considered on an individual basis after review of medical necessity and documented continued improvement in symptoms (such as HgbAlC for Type 2 Diabetes).

Iowa Total Care uses prior authorizations to ensure that all care delivered to our members is medically necessary and appropriate based on the member's type and severity of condition.

Who Qualifies Be an adult age 19 to 64. Have an income that does not exceed 133% of the Federal Poverty Level. Approximately $19,391 for an individual. Approximately $26,228 for a family of two (or higher depending on family size) Live in Iowa and be a U.S. citizen. Not be otherwise eligible for Medicaid or Medicare.

In 2023, the Medically Needy Income Limit (MNIL) for individuals is the same as for married couples and is $483 / month. The amount one must “spend down” can be thought of as a deductible. It is the difference between one's monthly income and the MNIL. In IA, the spend down is calculated for a 2-month period.

Step 2: Complete the form Complete form and be sure to sign the application. Step 3: Return form to HHS Return form to a local HHS office, email it to imaginingcenter4@dhs.state . ia.us or fax it to 515-564- 4016. Step 4: Wait It can take up to 45 days to process an application.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232