New Drug Classes

The Preferred Drug List (PDL) will be expanded for Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare on July 1, 2005. Refer to the following tables for preferred drugs in the new therapeutic classes that will be added to the PDL beginning July 1, 2005.

Alzheimer’s Agents Aricept Exelon Namenda Reminyl/Razadyne, ER Anticoagulants, Injectables Lovenox Antiparkinson’s Agents Benztropine Carbidopa/Levodopa Comtan Mirapex Pergolide Selegiline Stalevo Trihexyphenidyl Erythropoiesis Stimulating Proteins Procrit

Growth Hormones Nutropin Nutropin AQ Saizen Hepatitis C Agents Copegus Pegasys Peg-Intron Peg-Intron Redipen Rebetol Ribavirin Sedative Hypnotics Ambien Chloral hydrate Estazolam Flurazepam Temazepam Triazolam

Pharmacy Provider Requirements for the Preferred Drug List

Pharmacy providers should review the Wisconsin Medicaid Preferred Drug List Quick Reference in Attachment 1 of this Wisconsin Medicaid and BadgerCare Update for a complete list of preferred and non-preferred drugs. If medically appropriate for a recipient, prescribers are encouraged to try more than one preferred drug before a non-preferred drug is prescribed. Providers should note that most preferred drugs do not require prior authorization (PA), although they may have other restrictions (e.g., age, diagnosis). If a recipient presents a prescription to a pharmacy provider for a non-preferred drug, the pharmacy provider should contact the prescriber to discuss preferred drug options.

Non-preferred Drugs

If a non-preferred drug is medically necessary for a recipient, the prescriber is required to complete the appropriate Prior Authorization/Preferred Drug List (PA/PDL) form and submit it to a pharmacy provider. The prescriber is required to attest on the form that the recipient meets the clinical criteria for PA approval. Prescribers and pharmacy providers are required to retain a completed copy of the PA/PDL form. Refer to the “Available Prior Authorization/Preferred Drug List Forms” section of this Update for a list of PA/PDL forms.

Diagnosis-Restricted Drug Classes

The following new PDL drug classes are diagnosis restricted:

• Erythropoiesis stimulating proteins.
• Hepatitis C agents.

Non-preferred Diagnosis-Restricted Drugs

Prescribers should indicate a valid and approved diagnosis code for non-preferred drugs on the appropriate PA/PDL form. Refer to Attachment 2 for a list of diagnosis codes for non-preferred drugs in the erythropoiesis stimulating proteins and hepatitis C agent classes.

Preferred Diagnosis-Restricted Drugs

Pharmacy providers should continue to submit diagnosis codes on claims for preferred drugs. Select the Data Tables link from the Pharmacy page of the Wisconsin Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/ for a complete list of diagnosis codes for all diagnosis-restricted drugs.

Recipients Taking Antiparkinson’s Agents

Wisconsin Medicaid will allow eligible recipients who are taking a non-preferred antiparkinson’s agent to remain on that agent without PA. Recipients are required to have filled a prescription with a date of service (DOS) on and after April 1, 2005, to remain on the agent. If it is medically necessary to change the recipient to another non-preferred antiparkinson’s agent, PA is required.

Prior Authorization Required for Growth Hormone Drugs

Currently, all growth hormone drugs require PA. Effective for DOS on and after June 16, 2005, PA requests for preferred and non-preferred growth hormone drugs may be submitted to Wisconsin Medicaid via the Specialized Transmission Approval Technology - Prior Authorization (STAT-PA) system. The STAT-PA system is an efficient way for pharmacy providers to request PA approval from Wisconsin Medicaid. Pharmacy providers may continue to submit PA requests for growth hormone drugs using the paper PA process.

Current, approved PA requests for growth hormone drugs will be honored until their expiration date or until the approved days’ supply has been exhausted.

Documentation Requirements

Prescribers are required to provide clinical documentation on the Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs form, HCF 11092 (Dated 06/05)(fillable PDF, 140 KB), so that pharmacy providers can submit PA requests to Wisconsin Medicaid for growth hormone drugs.

Refer to Attachment 3 (PDF, 94 KB) and Attachment 4 (fillable PDF, 140 KB) for a copy of the PA/PDL for Growth Hormone Drugs form, completion instructions, and the clinical criteria requirements for PA approval.

Submitting Prior Authorization Requests

Prescribers should not submit PA/PDL forms to Wisconsin Medicaid. Instead, prescribers should send signed and completed PA/PDL forms to the pharmacy where the prescription will be filled. These forms may be faxed or mailed to the pharmacy or the recipient may carry the form, along with the prescription, to the pharmacy.

Prescribers may submit the appropriate PA/PDL form to pharmacy providers for non-preferred drugs in the new therapeutic classes listed in this Update and preferred and non-preferred growth hormone drugs beginning June 16, 2005.

Instructions for Pharmacy Providers

Pharmacy providers may begin submitting PA requests to Wisconsin Medicaid for non-preferred drugs in the new classes, including growth hormone drugs, using the STAT-PA system or the paper PA process on and after June 16, 2005.

Pharmacy providers may submit PA requests through the STAT-PA system by calling (800) 947-1197 or (608) 221-2096. Pharmacy providers also have the option of submitting PA requests on paper by mail or fax. Paper PA requests may be faxed to Wisconsin Medicaid at (608) 221-8616 or mailed to the following address:

Wisconsin Medicaid
Prior Authorization
Ste 88
6406 Bridge Rd
Madison WI 53784-0088

Pharmacy providers who submit PA requests using the STAT-PA system are required to indicate a diagnosis code on all PA requests.

Available Prior Authorization/Preferred Drug List Forms

The PA/PDL forms and completion instructions are available on the Forms page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/. These forms are also available on the Pharmacy page of the Medicaid Web site.

The following PA/PDL forms are available for drugs that do not require step therapy:

• The Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request form, HCF 11075 (Dated 09/04)(fillable PDF, 144 KB).
• The Prior Authorization/Preferred Drug List (PA/PDL) for Nonsedating Antihistamine Drugs, HCF 11082 (Dated 03/05)(fillable PDF, 75 KB).
• The PA/PDL for Growth Hormone Drugs (fillable PDF, 140 KB).

The following PA/PDL forms are available for drugs that require step therapy:

• The Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), HCF 11077 (Dated 12/04)(fillable PDF, 114 KB).
• The Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs, HCF 11078 (Rev. 05/05)(fillable PDF, 75 KB).

Emergency Medication Dispensing

An emergency medication supply may be dispensed in situations where the pharmacy provider deems it is necessary.

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim form, HCF 13072 (Rev. 06/03)(fillable PDF, 82 KB), with a Pharmacy Special Handling Request form, HCF 13074 (Rev. 06/03)(fillable PDF, 26 KB), indicating the nature of the emergency. Mail completed Noncompound Drug Claim forms and Pharmacy Special Handling Request forms to the address indicated on the Pharmacy Special Handling Request form. Medications dispensed in emergency situations do not require PA.

SeniorCare

Providers are reminded that Wisconsin SeniorCare does not cover over-the-counter drugs. Also, SeniorCare does not cover drugs that do not have a signed rebate agreement between the manufacturer and Wisconsin SeniorCare for SeniorCare participants in levels 2b and 3. Refer to the drug search tool on the SeniorCare Web site at dhs.wisconsin.gov/seniorcare/ for a complete list of covered drugs. The drug search tool is located on the Information for Providers page of the SeniorCare Web site.

For More Information

Changes to the PDL  and the PDL implementation schedule are posted on the Pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/. Refer to the following Updates for additional information:

• The September 2004 Update (2004-76), titled “Dispensing Provider Information on the Wisconsin Medicaid Preferred Drug List.”
• The December 2004 Update (2004-93), titled “Preferred Drug List Information for Dispensing Providers.”
• The March 2005 Update (2005-17), titled “New Preferred Drug List Information for Dispensing Providers.”

Providers can also refer to the ePocrates Web site at www2.epocrates.com/ to access and download the Wisconsin Medicaid and SeniorCare PDLs to their personal digital assistants (PDAs). Providers may call Provider Services at (800) 947-9627 or (608) 221-9883 for information about Wisconsin Medicaid, BadgerCare, and SeniorCare coverage of drugs.

Information Regarding Medicaid HMOs

This Update contains Medicaid fee-for-service policy and applies to providers of services to recipients on fee-for-service Medicaid only. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.

Attachment 1 — Preferred Drug List Quick Reference
Attachment 2 — Diagnosis-Restricted Drugs: Erythropoiesis Stimulating Protein and Hepatitis C Drug Classes
Attachment 3 — Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs Completion Instructions (PDF, 94 KB)
Attachment 4 — Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs (fillable PDF, 140 KB)