New Drug Classes

Beginning January 1, 2005, the Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare Preferred Drug List (PDL) will be expanded and preferred drugs will be added in several new therapeutic classes. Providers should refer to the table below for the new therapeutic classes.

Dispensing Provider Requirements for the Preferred Drug List

Dispensing providers should review the Wisconsin Medicaid Preferred Drug List Quick Reference in Attachment 1 of this Wisconsin Medicaid and BadgerCare Update for a list of preferred drugs. Preferred drugs do not require prior authorization (PA). Prescribers are encouraged to try more than one preferred drug, if medically appropriate for the recipient, before prescribing a non-preferred drug.

If a recipient presents a prescription to a dispensing provider for a non-preferred drug, the dispensing provider should contact the prescriber and discuss Medicaid preferred drug options.

If a non-preferred drug is medically necessary, the prescriber is required to complete and submit the appropriate Prior Authorization/Preferred Drug List (PA/PDL) form to the dispensing provider and document that the recipient meets the clinical criteria requirements for PA approval indicated below. Prescribers and dispensing providers are required to retain a completed copy of the PA/PDL form.

Note: On and after January 1, 2005, Vytorin^™ will be a preferred drug and Prevacid NapraPAC^™ will be a non-preferred drug.

Clinical Criteria Requirements for Prior Authorization Approval

The clinical criteria for PA approval of a non-preferred drug are:

• A treatment failure with a preferred drug(s).
• A condition that prevents the use of a preferred drug(s).
• A clinically significant drug interaction with another medication and a preferred drug(s).
• An intolerable side effect experienced while on a preferred drug(s).

Submitting Prior Authorization Requests

Beginning December 16, 2004, prescribers may begin submitting the appropriate PA/PDL form to dispensing providers for all therapeutic classes indicated in this Update, except for Proton Pump Inhibitor (PPI) drugs.

Dispensing providers may also begin obtaining PA on and after December 16, 2004, for the non-preferred drugs listed in this Update, except for the PPI drugs, using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or the paper PA process. Since PA may be obtained using the STAT-PA system, Wisconsin Medicaid should not receive PA/PDL forms unless the provider submits the PA request on paper.

In addition, dispensing providers may begin backdating STAT-PA requests up to 14 calendar days on and after December 16, 2004. Currently, the STAT-PA system restricts backdating to four calendar days.

The STAT-PA system can be accessed by calling (800) 947-1197 or (608) 221-2096. Paper PA requests can also be mailed to Wisconsin Medicaid at the following address:

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

Step Therapy

Proton Pump Inhibitor drugs and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are subject to specific step therapy requirements. Providers should refer to Attachment 2 for step therapy instructions for PPI drugs and Attachment 5 for step therapy instructions for NSAIDs.

Step Therapy for Proton Pump Inhibitor Drugs

Proton Pump Inhibitor drugs on the PDL require step therapy. Step therapy requires a recipient to try and fail one or more preferred drugs before obtaining PA for a non-preferred drug. The preferred PPI drug is Prilosec OTC^®.

On and after January 19, 2005, prescribers may begin submitting to dispensing providers the Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs form, HCF 11078 (Dated 12/04 [PDF, 81 KB]), for non-preferred PPI drugs. Current, approved PAs will be honored until their expiration date.

Dispensing providers should not submit PA requests for non-preferred PPI drugs for a SeniorCare participant until the participant has tried and failed Prilosec OTC^®. The cost of a 30-day supply of Prilosec OTC^® is comparable to the cost of a SeniorCare participant’s copayment for a brand name drug.

Clinical criteria for approval of a non-preferred PPI drug includes the following:

• The trial and failure of, or adverse reaction to, a preferred PPI drug.
• If the recipient is a child weighing less than 20 kilograms.
• If the recipient is a pregnant woman.

Providers may refer to Attachments 3 and 4 for the Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions, HCF 11078A (Dated 12/04 [PDF, 83 KB]), and a copy of the PA/PDL for PPI Drugs form (PDF, 81 KB).

Step Therapy for Non-Steroidal Anti-Inflammatory Drugs

Non-Steroidal Anti-Inflammatory Drugs on the PDL require the use of step therapy. Step therapy requires a recipient to try and fail one or more preferred drugs before obtaining PA for a non-preferred drug.

Preferred drugs in the NSAID therapeutic class include the following:

• Diclofenac.
• Etodolac.
• Fenoprofen.
• Fluriprofen.
• Ibuprofen.
• Indomethacin.
• Ketoprofen.
• Ketorolac.
• Meclofenamate.
• Nabumetone.
• Naproxen.
• Oxaprozin.
• Piroxicam.
• Sulindac.
• Tolmetin.

Clinical criteria for approval of a non-preferred NSAID include the following:

• The trial and failure of, or an adverse reaction to, a preferred NSAID.
• Risk factors, including:
  • If the recipient is over 65 years of age.
  • If the recipient has a history of ulcers or gastrointestinal (GI) bleeding.
  • If the recipient is currently taking anticoagulants.
• If the recipient is receiving treatment for a chronic condition.

Prescribers are required to complete and submit to the dispensing provider a Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) form, HCF 11077 (Dated 12/04 [PDF, 81 KB]), for non-preferred NSAIDs. Prescribers may refer to Attachments 6 and 7 for the Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Completion Instructions, HCF 11077A (Dated 12/04 [PDF, 81 KB]), and a copy of the PA/PDL for NSAIDs form.

The PA/PDL forms and completion instructions are also available on the forms page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/ or by calling Provider Services at (800) 947-9627 or (608) 221-9883.

Emergency Medication Dispensing

Providers are reminded that an emergency medication supply may be dispensed in situations where the dispensing 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. Medications dispensed in emergency situations do not require PA.

Send completed Noncompound Drug Claim forms and special handling requests to:

Wisconsin Medicaid
Pharmacy Special Handling
Ste 20
6406 Bridge Rd
Madison WI 53784-0020

For More Information

Changes to the PDL and the PDL implementation schedule will be posted to the pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/. Providers may refer to the September 2004 Update (2004-76), titled "Dispensing Provider Information on the Wisconsin Medicaid Preferred Drug List," for additional information about non-preferred drugs.

Providers can also refer to the ePocrates Web site at www.epocrates.com/ to access and download the Wisconsin Medicaid PDL to their personal digital assistants (PDAs).

Therapeutic Class	Preferred Drug Name
Angiotensin Converting Enzyme (ACE) inhibitor and calcium channel blocker combination drugs	Lexxel® Lotrel®	Tarka®
Antibiotic otic preparations	neomycin/polymixin/hydrocortisone Ciprodex®	Coly-mycin S® Floxin®
Antiviral drugs	acyclovir amantadine rimantadine HCl	Tamiflu® Valcyte® Valtrex®
Beta-adrenergic blocking agents	acebutolol atenolol betaxolol bisoprolol Coreg® labetalol metoprolol	nadolol pindolol propranolol sotalol timolol Toprol XL®
Calcium channel blocker drugs	Cardizem LA® diltiazem Dynacirc® felodipine	nicardipine nifedipine Norvasc® Sular®
Cephalosporins and related agents (e.g., cephalosporins, second and third generation, penicillins)	amoxicillin/clavulanate Augmentin XR® cefaclor cefadroxil	cefpodoxime cephalexin Omnicef® Spectracef®
Flurorquinolones	Avelox® ciprofloxacin Cipro® XR	Levaquin® Noroxin® Tequin®
Macrolides and ketolides	erythromycin	Zithromax®
Oral antifungal drugs	clotrimazole fluconazole Grifulvin V® Suspension	griseofulvin ketoconazole Lamisil® Nystatin
Proton Pump Inhibitor (PPI) drugs	Prilosec OTC®
Topical Immunomodulators	Elidel®	Protopic®

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.

Attachment1: Wisconsin Medicaid Preferred Drug List Quick Reference
Attachment 2: Step Therapy Instructions for Proton Pump Inhibitor Drugs
Attachment 3: Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions, HCF 11078A (PDF, 83 KB)
Attachment 4: Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs, HCF 11078 (PDF, 81 KB)
Attachment 5: Step Therapy Instructions for Non-Steroidal Anti-Inflammatory Drugs
Attachment 6: Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Completion Instructions, HCF 11077A (PDF, 83 KB)
Attachment 7: Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), HCF 11077 (PDF, 81 KB)