Effective immediately, providers are required to use the revised Prior Authorization/Preferred Drug List (PA/PDL) for Hypoglycemics for Adjunct Therapy form, HCF 11179 (06/07), when submitting prior authorization (PA) requests for preferred hypoglycemic drugs for adjunct hypoglycemic therapy.

Wisconsin Medicaid has revised section IIIC (Clinical Information for Januvia^™ and Janumet^™) of the PA/PDL for Hypoglycemics for Adjunct Therapy form to include Janumet^™. Recipients must meet specific PA criteria to receive Janumet^™.

Refer to Attachment 1 (PDF, 35 KB) and Attachment 2 (fillable PDF, 385 KB)of this Wisconsin Medicaid and BadgerCare Update for the revised completion instructions and form.

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, 35 KB)
Attachment 2 — Prior Authorization/Preferred Drug List (PA/PDL) for Hypoglycemics for Adjunct Therapy (fillable PDF, 385 KB) | Word (fillable, 103 KB)