Wisconsin Medicaid is revising diagnosis code restrictions and establishing quantity limits for Altabax^™, Bactroban^®, and mupirocin for Wisconsin Medicaid and BadgerCare recipients and Wisconsin SeniorCare participants.

Diagnosis Code Restrictions

Effective for claims processed on and after September 1, 2007, Wisconsin Medicaid has revised diagnosis code restrictions for the following drugs:

• Altabax^™ ointment, 1 percent.
• Bactroban^® cream, 2 percent.
• Bactroban^® nasal ointment, 2 percent.
• Mupirocin ointment, 2 percent.

The following are new diagnosis code restrictions:

Drug Name	Diagnosis Code	Description
Altabax™ ointment, 1%	684	Impetigo
Bactroban® cream, 2%	680-6829, 685-6869	Infections of skin and subcutaneous tissue
Bactroban® nasal ointment, 2%	V090	Methicillin-resistant staphylococcus aureus (MRSA)
mupirocin ointment, 2%	684	Impetigo
	680-6829, 685-6869	Infections of skin and subcutaneous tissue
	V090	Methicillin-resistant staphylococcus aureus (MRSA)

Note: Wisconsin Medicaid will no longer reimburse for the Centany^™ Ointment Kit for dates of service (DOS) on and after September 1, 2007.

Prior Authorization

If the prescriber writes a prescription with a diagnosis outside the Wisconsin Medicaid-allowed diagnoses for a drug, the pharmacy provider is required to submit a paper prior authorization (PA) request to Wisconsin Medicaid. The prescriber is required to complete the Prior Authorization/Drug Attachment (PA/DGA), HCF 11049 (06/03), and attach peer-reviewed medical literature to support the proven efficacy of the requested use of the drug. The prescriber should send the PA/DGA and supporting documentation to the pharmacy where the recipient intends to fill his or her prescription. The pharmacy provider then completes the Prior Authorization/Request Form (PA/RF), HCF 11018 (10/03), and submits the forms and supporting documentation to Wisconsin Medicaid. Refer to Attachment 1 (PDF, 21 KB) and Attachment 2 (fillable PDF, 55 KB) of this Wisconsin Medicaid and BadgerCare Update for the PA/DGA and completion instructions.

Prescriptions

Prescribers are required to indicate the diagnosis code or diagnosis description on prescriptions for all diagnosis-restricted drugs. If a diagnosis code is not indicated on the prescription, pharmacy providers should contact the prescriber to obtain the diagnosis code or diagnosis description. It is not acceptable for pharmacy providers to obtain the diagnosis code or diagnosis description from the recipient.

New Quantity Limits

Effective for DOS on and after September 1, 2007, quantities of Altabax^™, Bactroban^®, and mupirocin will be limited to the following.

Drug	Quantity Limit
Altabax™ ointment, 1%	30 grams per 34 days
Bactroban® cream, 2%	60 grams per 34 days
Bactroban® nasal ointment, 2%	10 grams per 34 days
mupirocin ointment, 2%	66 grams per 34 days

Claim Submission

For Drugs with New Diagnosis Code Restrictions

Pharmacy providers should submit claims for diagnosis-restricted drugs with the appropriate diagnosis code. When a claim is submitted with a missing or invalid diagnosis code, or with a code that is not a Medicaid-allowed diagnosis code, providers will receive Explanation of Benefits (EOB) code 510, which states the following:

Denied. Prior authorization/diagnosis is required for a payment of this service. A valid PA number/diagnosis is required and/or the procedure must match the approved PA.

If this EOB response is received because the provider did not submit a Medicaid-allowed diagnosis code, a paper PA request with supporting documentation should be submitted to Wisconsin Medicaid.

For Drugs with Quantity Limits

When a claim is submitted with a quantity that exceeds the limit, providers will receive the following:

• Explanation of Benefits code 485 that states: “Quantity limits exceeded.”
• National Council for Prescription Drug Programs reject code 76 that states, “Plan limitations exceeded.”

The pharmacy provider should contact the prescriber to determine that it is medically necessary for a recipient to exceed the quantity limits. If it is medically necessary, the pharmacy provider is required to complete the Noncompound Drug Claim, HCF 13072 (fillable PDF, 82 KB) (06/03), and a Pharmacy Special Handling Request, HCF 13074 (fillable PDF, 162 KB) (06/06), explaining the medical necessity to exceed the quantity limits. Refer to the Medicaid Web site at dhs.wisconsin.gov/medicaid/ for forms and instructions.

Pharmacy providers should contact the prescriber and indicate the following information on the Pharmacy Special Handling Request:

• Complete directions for use, including the length of treatment.
• Diagnosis.
• Location, size, and severity of the area to be treated.
• Complete information regarding prior medications that have been used to treat the condition and the results, when applicable.

Data Tables

Providers may refer to the Diagnosis Restricted Drugs data table and the new Quantity Limits data table on the Pharmacy section of the Medicaid Web site for the most recent information about diagnosis code restrictions and quantity limits. These tables may be revised at any time, so providers should refer to them frequently.

Emergency Medication Dispensing Reminder

An emergency medication supply may be dispensed in situations where the pharmacy provider or prescriber deem it is medically necessary. Medications dispensed in an emergency situation do not require PA.

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim with a Pharmacy Special Handling Request,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.

Providers may refer to the February 2007 Update (2007-14), titled “Emergency Medication Dispensing,” for more information about Medicaid’s emergency medication dispensing policy.

Attachment 1 — Prior Authorization/Drug Attachment Completion Instructions (PDF, 21 KB)
Attachment 2 — Prior Authorization/Drug Attachment (fillable PDF, 55 KB)  |  Word (fillable, 59 KB)