Multi-State Preferred Drug List

Wisconsin, along with several other states, has joined a multi-state Preferred Drug List (PDL). Beginning October 1, 2005, the Division of Health Care Financing is expanding and modifying the PDL and supplemental rebate program for Wisconsin Medicaid, BadgerCare, and SeniorCare.

Preferred Drug List recommendations are made to the Wisconsin Medicaid Pharmacy Prior Authorization (PA) Advisory Committee based on the therapeutic significance of individual drugs and the cost-effectiveness and supplemental rebates with drug manufacturers. Drugs included on the PDL are recommended to the PA Advisory Committee based on research from peer-reviewed medical literature, drug studies and trials, and clinical information prepared by clinical pharmacists.

Preferred Drug List Changes

Wisconsin Medicaid has added new classes to the PDL and made changes to previously reviewed classes. The tables on the following pages contain the preferred drugs in each class.

If a drug in a previously reviewed class has changed from a preferred drug to a non-preferred drug, PA is required for future refills of the non-preferred drug. Current, approved PAs for drugs that remain non-preferred will be honored until their expiration date or until services have been exhausted.

Pharmacy providers may continue to submit PA requests to Wisconsin Medicaid for previously reviewed classes. For non-preferred drugs in the classes listed below, PA requests may be submitted to Wisconsin Medicaid on and after September 16, 2005:

• Hypoglycemics, metformins.
• Platelet aggregation inhibitors.
• Stimulants and related agents.

Prescriber and pharmacy provider responsibilities for the PDL remain unchanged.

New Preferred Drug List Classes

The following are new drug classes and preferred drugs that will be added to the PDL on October 3, 2005.

Angiotensin Converting Enzyme (ACE) Inhibitors benazepril/HCTZ captopril/HCTZ enalapril/HCTZ fosinopril/HCTZ lisinopril/HCTZ quinapril/HCTZ Hypoglycemics, Metformins Avandamet glyburide-metformin metformin ER, IR

Platelet Aggregation Inhibitors Aggrenox dipyridamole Plavix ticlopidine Stimulants and Related Agents Adderall XR amphetamine salt combination Concerta dextroamphetamine Focalin, XR Metadate CD methylphenidate ER, IR Ritalin LA

Previously Reviewed Preferred Drug List Classes

The following drug classes have been previously reviewed by Wisconsin Medicaid, and preferred drugs are listed.

Alzheimer’s Agents Aricept Exelon Namenda Reminyl/Razadyne, ER Antiemetics, Oral Emend Zofran, ODT Antifungals, Oral clotrimazole fluconazole griseofulvin Gris-Peg itraconazole ketoconazole Lamisil Mycostatin nystatin Vfend Antifungals, Topical ciclopirox cream, suspension clotrimazole clotrimazole/betamethasone econazole nitrate Exelderm ketoconazole Loprox gel, shampoo nystatin nystatin/triamcinolone Antiparkinson’s Agents benztropine carbidopa/levodopa Comtan Kemadrin Mirapex pergolide Requip selegiline Stalevo trihexyphenidyl Antivirals, Influenza amantadine rimantadine Antivirals, Other acyclovir ganciclovir Valcyte Valtrex Bone Resorption Suppression and Related Agents Actonel Fosamax, Plus D Miacalcin Bronchodilators, Anticholinergic Atrovent, HFA Combivent ipratropium Spiriva Bronchodilators, Beta Agonists albuterol Maxair metaproterenol Serevent terbutali Cephalosporins and Related Agents (Cephalosporins, Second and Third Generation, Penicillins) amox tr-potassium clavulanate 600 amoxicillin/clavulanate Cedax cefaclor cefadroxil cefpodoxime cefuroxime Cefzil cephalexin Omnicef Spectracef Suprax Fluoroquinolones Avelox ciprofloxacin Levaquin ofloxacin Glucocorticoids, Inhaled Advair Diskus Aerobid, Aerobid-M Azmacort Flovent Pulmicort Respules Qvar

Hypoglycemics, Insulins Humulin Humalog Humalog Mix Lantus Intranasal Rhinitis Agents Flonase flunisolide ipratropium Nasacort AQ Nasonex Leukotriene Modifiers Accolate Singulair Macrolides/Ketolides Biaxin XL clarithromycin erythromycin Zithromax Nonsteroidal Anti-Inflammatory Agents diclofenac potassium diclofenac sodium, XL etodolac, XL fenoprofen flurbiprofen ibuprofen indomethacin, SR ketoprofen ketorolac meclofenamate nabumetone naproxen naproxen sodium, DS oxaprozin piroxicam sulindac tolmetin, DS Ophthalmics, Allergic Conjunctivitis Acular Alrex cromolyn Elestat Patanol Ophthalmics, 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 Sedative Hypnotics Ambien chloral hydrate estazolam flurazepam temazepam triazolam Topical Immunomodulators Elidel Protopic

Grandfathering

Effective on and after October 3, 2005, Wisconsin Medicaid will grandfather recipients who are currently taking non-preferred drugs in the following classes:

• Angiotensin Converting Enzyme (ACE) inhibitors.
• Ophthalmics, glaucoma agents.
• Stimulants and related agents.

Recipients currently taking a non-preferred ACE inhibitor may remain on the drug until January 1, 2006, without PA. Recipients currently using a non-preferred drug in the ophthalmics, glaucoma agent class may remain on the drug for one year without PA. Recipients currently taking a non-preferred stimulant or related agent may remain on the drug indefinitely without PA.

If it is medically necessary for a prescriber to change a recipient to another non-preferred drug in a grandfathered drug class, PA is required.

Angiotensin Converting Enzyme Inhibitors

Effective on and after October 3, 2005, ACE inhibitors will be added to the PDL.

Pharmacy providers should discontinue using the STAT-PA Drug Worksheet for Brand Name ACE Inhibitors, HCF 11057. Effective on and after October 3, 2005, prescribers should complete the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request form, HCF 11075 (fillable PDF, 144 KB) (09/04), and submit the form to pharmacy providers for non-preferred ACE inhibitors.

Current, approved PAs for ACE inhibitors will be honored until their expiration date.

Non-Steroidal Anti-Inflammatory Drugs

Effective on and after October 3, 2005, Wisconsin Medicaid will remove the step- therapy restrictions for drugs in the Non-Steroidal Anti-Inflammatory Drug (NSAID) class. However, recipients will now be required to try and fail two preferred NSAIDs before a non-preferred NSAID can be prescribed. The revised completion instructions and Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) form, HCF 11077 (Rev. 09/05), are located in Attachment 1 and Attachment 2 of this Wisconsin Medicaid and BadgerCare Update and may also be downloaded and printed from the Medicaid Web site.

Current, approved PAs for NSAIDs will be honored until their expiration date.

Stimulants and Related Agents

Effective on and after October 3, 2005, stimulants and related agents will be added to the PDL. Agents in this drug class will remain diagnosis restricted.

For non-preferred drugs in this class, prescribers should indicate a stimulant-approved diagnosis code on the Wisconsin Medicaid Prior Authorization/Preferred Drug List (PA/PDL) for Stimulants and Related Agents form, HCF 11097 (09/05). The completion instructions and PA/PDL for Stimulants and Related Agents form are located in Attachment 3 (PDF, 32 KB) and Attachment 4 (fillable PDF, 158 KB) of this Update for photocopying and may also be downloaded and printed from the Medicaid Web site.

Strattera Approval Criteria

For approval of a PA request for Strattera, a recipient must meet one of the following criteria:

• A diagnosis of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) and Tourette’s Syndrome or a history of tics.
• A diagnosis of ADD or ADHD and obsessive compulsive disorder.
• A medical history of substance abuse or misuse.
• A history or serious risk of diversion (e.g., someone living in the home with a history of substance abuse or misuse).
• A trial and failure of or adverse reaction to a preferred stimulant or related agent.

A PA request for a non-preferred stimulant or related agent will be approved if one of the previously listed criteria is met.

Preferred Diagnosis-Restricted Drugs

As a reminder, pharmacy providers should continue to submit diagnosis codes on claims for preferred diagnosis-restricted drugs. 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 all diagnosis-restricted drugs.

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 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 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Completion Instructions (PDF, 28 KB)
Attachment 2 — Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (fillable PDF, 116 KB)
Attachment 3 — Prior Authorization/Preferred Drug List (PA/PDL) for Stimulants and Related Agents Completion Instructions (PDF, 32 KB)
Attachment 4 — Prior Authorization/Preferred Drug List (PA/PDL) for Stimulants and Related Agents (fillable PDF, 158 KB)