Some covered services or prescription drugs may need approval from Iowa Total Care, and this is called a Prior Authorization (PA). You do not need a paper referral from Iowa Total Care to see a doctor. But, your doctor may need to request approval from Iowa Total Care before you receive the service.
You can check to see if your service was approved by logging into your Member Portal.
Some Medicaid members have a copay for some brand name prescription drugs. You can find more information on copays on the Pharmacy Benefits page.
Below is a list of services that may require approval. Most services require approval if performed by a doctor who is not in the Iowa Total Care network (also known as an out-of-network provider). There are services that require approval even if the doctor is part of our network. Use our Find a Provider tool to locate a provider in our network.
Yes, for some services
Includes ground and emergency helicopter
Ambulance transportation from one healthcare facility to another is only covered when it is medically necessary, arranged for and approved by an in-network provider.
Yes, for some services
Age limitations may apply. Services include crisis stabilization, inpatient psychiatric hospitalization, outpatient assessment and treatment services, peer support, residential treatment facilities, and rehabilitation services.
Yes, for some services
Coverage is limited to manual treatment of the spine and one set of spinal x-rays per year.
Start of care – No
Ongoing care – Yes, for some services
Durable Medical Equipment (DME)
Items that are not medically necessary and are not ordered by a provider are not covered.
Yes, in some situations
Use a pharmacy in our network. This can include mail-order pharmacies. Prescription drugs and OTC items approved by the U.S. Food and Drug Administration (FDA).
Yes, for some medications
Drugs: over the counter (OTC)
Over the counter medications require a doctor's prescription.
Yes, for some OTC medications
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)/Well-child exam
Services are for members age 20 and younger. Sports and school physicals annually.
Eye care services and eyeglasses
Iowa Health Link members: One complete preventive eye exam every 12 months. At least one pair of eyeglasses every 12 months for ages seven and younger. Ages eight and older, one pair of eyeglasses every 24 months.
Hawki members: $100 retail toward eyeglasses every 12 months.
Family planning services can be from any Medicaid doctor. This includes well-women exams, screening, and pregnancy testing.
Foot care visits may be limited. Orthotics are covered for some conditions for some eligibility categories.
Yes, in some situations
Hearing aids and services
Hearing aids and services.
Yes, for cochlear implants
High-risk prenatal and infant services
Care management provides special support for members at risk or with special health needs.
Home health care
Care must be prescribed by your doctor. Other conditions apply.
First 4 visits – No
Ongoing care – Yes
Other than an inpatient facility.
Start of care – No
Ongoing care – Yes, for some services
Immunizations for children
Available to members age 21 and younger.
Inpatient hospital care
Items that are not medically necessary are not covered.
Yes, including observation services
Outpatient hospital care
Items that are not medically necessary are not covered.
Yes, for some services
Lab services and testing
Paternity testing and infertility treatment tests are not covered.
Yes, for some services
See your doctor as soon as you know you are pregnant. Send us the Notice of Pregnancy form at first visit. Prenatal through postpartum services are covered.
Yes, for some services
Nurse midwife services
Covered with all in network providers.
Yes, for non-participating providers
Covered with all in network providers.
Yes, for non-participating providers
Orthotics/Prosthetics are covered for some eligibility categories
Pain services during and after surgery do not require authorization
All other pain services do require authorization.
One routine physical exam every 12 months performed by your PCP. Health visits as needed.
Private duty nurse services
Overnight nursing services and respite care hours are limited.
Psychiatric hospital services
Psychiatric hospital services
Yes, for some services
Yes, for some services
Radiology and x-rays
Must be ordered by a doctor.
Yes, for high-tech radiology, including CT, MRI, MRA
Surgery that is performed to make you look better and is determined to be cosmetic is not covered.
Skilled Nursing Facility care
Items that are not medically necessary are not covered. This includes private rooms or convenience/comfort items.
Some eligibility categories have a limit to total number of days.
Sterilizations require informed consent forms 30 days prior to the date of procedures. Hysterectomies are covered on a limited basis.
Therapy services. Includes occupational, physical and speech therapies.
Some eligibility categories have limits to total number of visits
Yes, after the first 4 sessions
Stop smoking/ tobacco cessation
Certain medications, patches, or gum to help you stop smoking are covered. Smoking cessation is covered through Tobacco-Free-Iowa. Call 1-800-QUIT-NOW (784-8669) for more information.
Yes, for some services.
No authorization required in an emergency