Preferred Drug List Changes

Wisconsin Medicaid has added new classes to the Preferred Drug List (PDL) and made changes to previously reviewed classes. Changes apply to Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare. The tables on the following pages contain the preferred drugs in each new and reviewed class. As a reminder, prior authorization (PA) is always required for non-preferred drugs and future refills of new non-preferred drugs.

When prescribing non-preferred drugs, prescribers are reminded to complete, sign, and date the appropriate Prior Authorization/Preferred Drug List (PA/PDL) form and submit it to a pharmacy provider.

New Classes Available on the Preferred Drug List

Wisconsin Medicaid has reviewed and will add androgenic agents, selective serotonin reuptake inhibitor (SSRI) drugs, and hypoglycemics for adjunct therapy to the PDL effective for dates of service (DOS) on and after October 2, 2006.

Androgenic Agents

The following are preferred androgenic agents:

Androgenic Agents

Androderm

Androgel

Wisconsin Medicaid will begin accepting PA requests for non-preferred drugs in this class beginning September 15, 2006.

Selective Serotonin Reuptake Inhibitor Drugs

The following are preferred SSRI drugs:

Selective Serotonin Reuptake Inhibitors

citalopram

fluoxetine

fluvoxamine

paroxetine

Zoloft

Effective for DOS on and after October 2, 2006, for non-preferred SSRI drugs, providers are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, HCF 11075 (Rev. 06/06). Providers are required to discontinue using the STAT-PA Drug Worksheet for SSRI Drugs on October 2, 2006. A copy of the completion instructions (PDF, 22 KB) and the PA/PDL Exemption Request form (fillable PDF, 29 KB) may be found on the Wisconsin Medicaid Web site.

Hypoglycemic Drugs for Adjunct Therapy

The following are preferred hypoglycemic drugs for adjunct therapy:

Hypoglycemics, Adjunct Therapy

Byetta†

Symlin†

† Preferred agents that require clinical prior authorization.

Both drugs in this class are preferred; however, specific PA criteria are required. To obtain PA, providers are required to complete the PA/PDL for Hypoglycemics for Adjunct Therapy form, HCF 11179 (09/06). Refer to Attachment 1 (PDF, 42 KB) and Attachment 2 (fillable PDF, 389 KB) of this Wisconsin Medicaid and BadgerCare Update for the form and completion instructions. A copy of the completion instructions and the PA/PDL for Hypoglycemics for Adjunct Therapy form may be found on the Wisconsin Medicaid Web site.

Specific PA criteria for Byetta include all of the following:

• If the recipient has a diagnosis of Type II diabetes.
• If the recipient has failed to achieve adequate glycemic control despite individualized diabetic medication management.
• If the recipient is receiving ongoing medical care from a health care professional trained in diabetes management.

Specific PA criteria for Symlin include the following:

• If the recipient has a diagnosis of Type I or Type II diabetes.
• If the recipient has failed to achieve adequate glycemic control despite optimal insulin management, including the use of meal time insulin.
• If a recipient is receiving ongoing medical care from a health care professional trained in diabetes management.

If the recipient has any of the following, the PA request for Symlin will be returned:

• An Hemoglobin A1c (HbA1c) greater than 9 percent.
• Recurrent, severe hypoglycemia unawareness.
• A diagnosis of gastroparesis.

Reviewed Classes on the Preferred Drug List

Wisconsin Medicaid has reviewed the following existing PDL drug classes and the preferred drugs are listed below. Changes to the PDL will be effective for DOS on and after October 2, 2006, except as noted. Current, approved PA requests will be honored until their expiration date or until services have been exhausted.

Angiotensin Converting Enzyme (ACE) Inhibitors benazepril, HCTZ captopril, HCTZ enalapril, HCTZ fosinopril, HCTZ lisinopril, HCTZ Alzheimer’s Agents Aricept Exelon Namenda Anticonvulsants carbamazepine Carbatrol Celontin clonazepam Depakote, ER, sprinkle Diastat Equetro ethosuximide Felbatol gabapentin Gabitril Keppra Lamictal lamotrigine 25 mg Lyrica Mebaral mephobarbital Peganone phenobarbital phenytoin primidone Topamax Trileptal valproic acid zonisamide Antiemetics, Oral Emend Zofran, ODT Antifungals, Oral clotrimazole fluconazole griseofulvin Gris-Peg itraconazole ketoconazole nystatin Mycostatin Vfend Antifungals, Topical ciclopirox cream, suspension clotrimazole/betamethasone econazole nitrate ketoconazole nystatin nystatin/triamcinolone Anti-Parkinson’s Agents benztropine carbidopa/levodopa Comtan Kemadrin Mirapex pergolide Requip selegiline Stalevo trihexyphenidyl Antivirals, Influenza amantadine Relenza rimantadine Tamiflu Antivirals, Other acyclovir ganciclovir Valcyte Valtrex Bone Resorption Suppression and Related Agents* Fosamax, Plus D Miacalcin * Changes to this class will be effective for DOS on and after December 1, 2006. Bronchodilators, Anticholinergic Atrovent, HFA Combivent ipratropium Spiriva Bronchodilators, Beta Agonists albuterol Maxair metaproterenol Proventil HFA Serevent terbutaline Xopenex HFA Cephalosporins and Related Agents amoxicillin/clavulanate amox tr-potassium clavulanate 600 Cedax cefaclor cefadroxil cefpodoxime cefprozil cefuroxime cephalexin Omnicef Spectracef Suprax Cytokine and Cell Adhesion Molecule Antagonists Enbrel† Humira† Kineret† Raptiva† † Preferred agents that require clinical PA.

Fluoroquinolones Avelox ciprofloxacin Levaquin ofloxacin Glucocorticoids, Inhaled Advair, HFA Aerobid, Aerobid-M Asmanex Azmacort Flovent Pulmicort Respules Qvar Hypoglycemics, Insulin and Related Agents Humalog Humalog Mix Humulin Lantus Levemir Hypoglycemics, Thiazolidinediones Actos Avandamet Avandaryl Avandia Intranasal Rhinitis Agents Astelin Flonase flunisolide ipratropium Nasacort AQ Nasonex Leukotriene Modifiers Accolate Singulair Macrolides/Ketolides azithromycin Biaxin XL clarithromycin erythromycin Zmax Nonsteroidal Anti-inflammatory Drugs diclofenac, potassium, XL etodolac, XL flurbiprofen ibuprofen indomethacin, SR ketoprofen ketorolac meclofenamate meloxicam nabumetone naproxen naproxen sodium, DS oxaprozin piroxicam sulindac Ophthalmics, Allergic Conjunctivitis Acular Alrex cromolyn Elestat ketotifen Patanol Ophthalmic Antibiotics bacitracin/polymyxin ciprofloxacin solution erythromycin gentamicin ofloxacin polymyxin/trimethoprim sulfacetamide tobramycin triple antibiotic Zymar Ophthalmics, Glaucoma Agents Alphagan P Azopt betaxolol Betimol Betopic S brimonidine carteolol Cosopt dipivefrin levobunolol Lumigan metipranolol pilocarpine timolol Travatan Trusopt Platelet Aggregation Inhibitors Aggrenox dipyridamole Plavix ticlopidine Stimulants and Related Agents Adderall XR amphetamine salt combination Concerta dextroamphetamine Focalin, XR Metadate CD methylphenidate ER Ritalin LA Strattera* * Prior authorization is not required for recipients who are 18 and older. Topical Immunomodulators Elidel Protopic

Grandfathered Prescriptions

Effective for DOS on and after October 2, 2006, Wisconsin Medicaid will grandfather prescriptions for recipients who are currently taking non-preferred drugs in the following classes. Recipients currently taking these drugs may remain on the drug indefinitely without PA.

Fall 2006 Grandfathered Drugs
Drug Class	Non-preferred Drug
Alzheimer’s agents	Cognex, Razadyne, Razadyne ER
Selective serotonin reuptake inhibitor drugs	Lexapro, Paxil CR, Pexeva, Prozac Weekly, sertraline
Stimulants and related agents	Ritalin LA

Refer to Attachment 5 for a complete list of drug classes that may be grandfathered.

Grandfathering Ends for Xalatan and Istalol

Prescriptions for Xalatan and Istalol will no longer be grandfathered effective for DOS on and after January 1, 2007. These drugs will continue to be non-preferred drugs. Therefore, providers are required to prescribe a preferred drug or submit a PA request to Wisconsin Medicaid for Xalatan or Istalol.

Current, approved PA requests for Xalatan and Istalol will be honored until their expiration date.

Strattera

Prior authorization is not required for Strattera for recipients who are 18 years of age and older; however, PA is required for Strattera for recipients who are younger than 18 years of age. Providers are still required to indicate a diagnosis code on all claims for Strattera. For diagnosis codes, providers may refer to the Pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/.

When prescribing Strattera, prescribers are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) for Stimulants and Related Agents, HCF 11097 (06/06). A copy of the completion instructions (PDF, 25 KB) and the PA/PDL for Stimulants and Related Agents (fillable PDF, 37 KB) may be found on the Wisconsin Medicaid Web site.

Providers may refer to the September 2005 Update (2005-60), titled “Wisconsin Medicaid Enters Multi-State Preferred Drug List and Supplemental Rebate Program,” for the PA criteria for Strattera.

Lamisil

Lamisil is an oral antifungal drug that has specific PA approval criteria. To request PA for Lamisil, providers are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) for Lamisil form, HCF 11180 (09/06). Refer to Attachment 3 (PDF, 36 KB) and Attachment 4 (fillable PDF, 174 KB) for the and completion instructions and form.

Wisconsin Medicaid may approve a PA request for Lamisil if the recipient has tried and failed, or had an adverse reaction to, a preferred drug, or if the recipient has a diagnosis of onychomycosis or other fungal skin infection (e.g., tinea). If the recipient has a diagnosis of onychomycosis, the recipient must also have a positive potassium hydroxide (KOH) test, culture, or nail biopsy.

If the recipient has a diagnosis of onychomycosis, the recipient must also have one of the following to receive Lamisil:

• Onychomycosis in the fingernail bed.
• A diagnosis of Type I or Type II diabetes.
• Be immunocompromised.
• A severe disability that is a result of the fungal infection.

For all other non-preferred oral antifungal drugs, providers are required to complete only the PA/PDL Exemption Request form (fillable PDF, 29 KB).

Brand Medically Necessary Exclusions

When some generic drugs become available, they initially may be more costly for Wisconsin Medicaid than their brand counterparts due to federal and supplemental rebates. For this reason, certain PDL drugs are excluded from the brand medically necessary drug requirements published in the August 2004 Update (2004-62), titled “Pharmacy Information on Prior Authorization Requirements for Brand Medically Necessary Drugs.” Currently, Flonase, Zocor, and Zoloft are preferred drugs that are excluded from the brand medically necessary policy. Their generics, fluticasone, simvastatin, and sertraline, are non-preferred drugs that require PA.

Effective for DOS on and after September 18, 2006, pharmacy providers may indicate National Council for Prescription Drug Programs Dispense as Written (DAW) code “6” on claims for Flonase, Zocor, and Zoloft. Providers may only submit claims with DAW code “6” for these drugs.

For drugs excluded from brand medically necessary requirements, the following guidelines apply:

• The prescriber is not required to indicate “Brand Medically Necessary” on the prescription.
• The pharmacy provider is not required to obtain PA for the brand name drug.
• The pharmacy provider should dispense the brand name drug.
• SeniorCare participants and Medicaid recipients will pay the generic drug copayment, not the brand-name copayment.
• The generic equivalent requires PA. If the pharmacy provider attempts to dispense and submit a claim for the generic equivalent, he or she will receive a message that PA is required.

Note: SeniorCare participants and Medicaid recipients may request an adjustment and refund of brand-name copayments made for Zocor for prescriptions filled on DOS on and after July 1, 2006. To do this, the pharmacy provider should reverse and resubmit the claim(s) for Zocor. The pharmacy provider should reimburse the recipient for the difference between the brand-name and generic copayments; Wisconsin Medicaid will reimburse pharmacy providers this amount.

Reversals and Adjustments

Pharmacy providers may submit online reversals through the Point-of-Sale (POS) system up to 90 days from the DOS. To request adjustments more than 90 days from the DOS, pharmacy providers are required to submit requests on paper using the Adjustment/Reconsideration Request form, HCF 13046 (fillable PDF, 91 KB) (Rev. 08/05).

Diagnosis-Restricted Drugs

Drugs that are diagnosis restricted continue to be diagnosis restricted even if they are a preferred drug on the PDL. Pharmacy providers should continue to submit diagnosis codes on claims for preferred diagnosis-restricted drugs. If a drug is both diagnosis restricted and non-preferred, pharmacy providers are required to indicate the appropriate diagnosis code on the PA request if it is submitted through the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or on paper.

Refer to the Pharmacy Data Tables on the Pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/ for a list of diagnosis codes for preferred diagnosis-restricted drugs.

Tamiflu^® Reminder

As a reminder, specific requirements for prescribing Tamiflu^® include the following:

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

Emergency Medication Dispensing Reminder

An emergency medication supply may be dispensed in situations where the pharmacy provider or prescriber deem it is medically necessary.

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

The Pharmacy Special Handling Request form and completion instructions are located in Attachment 6 (PDF, 18 KB) and Attachment 7 (fillable PDF, 162 KB) for photocopying and may also be downloaded and printed from the Medicaid Web site.

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. Both preferred and non-preferred drugs are included on the 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 www.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 — Prior Authorization/Preferred Drug List (PA/PDL) for Hypoglycemics for Adjunct Therapy Completion Instructions (PDF, 42 KB)
Attachment 2 — Prior Authorization/Preferred Drug List (PA/PDL) for Hypoglycemics for Adjunct Therapy (fillable PDF, 389 KB)
Attachment 3 — Prior Authorization/Preferred Drug List (PA/PDL) for Lamisil Completion Instructions (PDF, 36 KB)
Attachment 4 — Prior Authorization/Preferred Drug List (PA/PDL) for Lamisil (fillable PDF, 174 KB)
Attachment 5 — Grandfathered Drugs
Attachment 6 — Pharmacy Special Handling Request Completion Instructions (PDF, 18 KB)
Attachment 7 — Pharmacy Special Handling Request (fillable PDF, 162 KB)