Claim Submission Requirements for Tamiflu^® and Relenza^®

Effective for dates of service (DOS) on and after March 1, 2006, Tamiflu^® (oseltamivir) and Relenza^® (zanamivir) will be added to the Wisconsin Medicaid Preferred Drug List (PDL) as preferred drugs. Prior authorization (PA) is no longer required for Tamiflu^® or Relenza^®.

Claims may be submitted for these drugs to Wisconsin Medicaid for DOS on and after March 1, 2006. Clinical requirements for prescribing Tamiflu^® or Relenza^® include the following:

• If the recipient is in the first 24 to 36 hours of experiencing signs and symptoms of influenza.
• If the recipient is immunosuppressed or at increased risk of experiencing serious medical complications from, or exposure to, influenza.

Revised Byetta^® Prior Authorization Criteria and Documentation Requirements

Providers who prescribe Byetta^® (exenatide) are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request form, HCF 11075 (Dated 09/04), (fillable PDF, 144 KB) so that a pharmacy provider can submit a PA request to Wisconsin Medicaid through the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system.

Prescribers are required to complete Elements 14 and 28 on the PA/PDL Exemption Request form. In Element 14, prescribers are required to indicate if the recipient has a condition preventing the use of a preferred drug. In Element 28, prescribers should indicate the following:

• If the recipient has a diagnosis of Type 2 diabetes.
• If Byetta^® is being used concurrently with any oral diabetic agents, such as sulfonylureas or metformins. Providers are required to specify which drugs are being used.

If a prescription is written by a prescriber other than an endocrinologist, the recipient is required to be closely monitored by a diabetic educator. The prescriber must confirm and document this information on the PA/PDL Exemption Request form. Prescribers should not submit PA/PDL forms to Wisconsin Medicaid. Instead, prescribers should send the signed and completed PA/PDL forms to a pharmacy provider. These forms may be faxed or mailed to the pharmacy provider, or the recipient may carry the forms, along with the prescription, to the pharmacy provider.

Note:

Prescriber and pharmacy provider responsibilities for the PDL remain unchanged.

Emergency Medication Dispensing

An emergency medication supply may be dispensed in situations where the prescriber deems it is medically 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. Providers should mail completed Noncompound Drug forms and Pharmacy Special Handling Requests to the address indicated on the Pharmacy Special Handling Request form. Medications dispensed in emergency situations do not require PA.

For More Information

Providers should refer to the PDL page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/pdl/index.htm for the most current PDL.

The PDL may be revised as changes occur. Changes to the PDL are posted on the Pharmacy page of the Medicaid Web site. 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 Wisconsin Medicaid and BadgerCare 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.