Preferred Drug List Changes

Effective for dates of service (DOS) on and after January 3, 2008, changes will be made to certain Preferred Drug List (PDL) drug classes. Changes will be made to the following drug classes:

• Anti-Parkinson’s agents.
• Bone resorption suppression and related agents.
• Intranasal rhinitis agents.
• Ophthalmics for allergic conjunctivitis.

To request prior authorization (PA) for non-preferred drugs in these classes, providers are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, HCF 11075 (fillable PDF, 205 KB) (12/06). Providers may submit PA requests for drugs in these classes using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system beginning December 18, 2007.

Anti-Parkinson’s Agents

Effective for DOS on and after January 3, 2008, Comtan^® and Mirapex^® will be non-preferred drugs. Prior authorization is required for these drugs for DOS on and after January 3, 2008, or recipients may be switched to a preferred agent. Providers are required to indicate an allowable diagnosis code on PA requests for Mirapex^®.

Wisconsin Medicaid will grandfather recipients taking Mirapex^® to treat Parkinson’s disease when an allowable diagnosis code for Parkinson’s disease was indicated on claims submitted between October 1, 2007, and January 3, 2008.

For a new prescription for Mirapex^® or for a current prescription where Mirapex^® is used to treat restless leg syndrome (RLS), the provider is required to change the recipient to a preferred drug or request PA for the non-preferred drug.

Recipients currently taking Comtan^® will be grandfathered.

The following are preferred anti-Parkinson’s agents.

Anti-Parkinson’s Agents

benztropine

carbidopa/levodopa

Kemadrin

Requip

selegiline

Stalevo

trihexyphenidyl

Bone Resorption Suppression and Related Agents

Effective for DOS on and after January 3, 2008, Actonel^® will be a non-preferred drug. Prior authorization is required for Actonel^® for DOS on and after January 3, 2008. Providers are required to change recipients’ prescriptions to a preferred bone resorption suppression and related agent or submit a PA request to Wisconsin Medicaid for Actonel^®. Providers received a letter in November 2007 explaining the change to this drug class. (Refer to Attachment 1 (PDF, 40 KB) of this Wisconsin Medicaid and BadgerCare Update for a copy of the letter.) The following are preferred bone resorption suppression and related agents.

Bone Resorption Suppression and Related Agents

Fosamax, Plus D

Miacalcin

Intranasal Rhinitis Agents

Effective for DOS on and after January 3, 2008, Nasonex^® will be a non-preferred drug. Prior authorization is required for Nasonex^® for DOS on and after January 3, 2008. Providers are required to change recipients’ prescriptions to a preferred intranasal rhinitis agent or submit a PA request to Wisconsin Medicaid for Nasonex^®. Providers received a letter in November 2007 explaining the change to this drug class. (Refer to Attachment 1 (PDF, 40 KB) for a copy of the letter.) The following are preferred intranasal rhinitis agents.

Intranasal Rhinitis Agents

Astelin

Flonase

flunisolide

ipratropium

Nasacort AQ

Ophthalmics, Allergic Conjunctivitis

Effective for DOS on and after January 3, 2008, the following are preferred ophthalmic drugs for allergic conjunctivitis.

Ophthalmics, Allergic Conjunctivitis

Alaway

cromolyn sodium

Zaditor OTC

All other drugs in this class are non-preferred and require trial and failure of a preferred drug before a PA request may be submitted to Wisconsin Medicaid.

For Wisconsin SeniorCare participants, cromolyn sodium is the only preferred drug in this class. Alaway^™ and Zaditor^® OTC are available over-the-counter and are not covered by SeniorCare.

Prior Authorization Request Submissions

Providers may submit PA requests using the STAT-PA system or on paper.

STAT-PA

Pharmacy providers should submit PA requests using the STAT-PA system, if possible. Prescribers are required to complete and sign the appropriate PA/PDL form and submit it to the pharmacy where the prescription will be filled. The pharmacy provider may submit the PA request using the STAT-PA system.

Paper

Prescribers are required to complete and sign the appropriate PA/PDL form and submit it to the pharmacy where the prescription will be filled. The pharmacy provider is required to complete and sign a Prior Authorization Request Form (PA/RF), HCF 11018 (10/03), and submit it with the PA/PDL form and any supporting documentation to Wisconsin Medicaid.

New Prior Authorization/Preferred Drug List Forms

The following disease-specific PA/PDL forms will be required for use on and after January 16, 2008:

• Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis, HCF 11304 (11/07).
  • PDF (fillable, 323 KB)
  • Word ( fillable, 63 KB)
• Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease, HCF 11305 (11/07).
  • PDF (fillable, 244 KB)
  • Word (fillable, 64 KB)
• Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis, HCF 11306 (11/07).
  • PDF (fillable, 353 KB)
  • Word (fillable, 60 KB)
• Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriatic Arthritis, HCF 11307 (11/07).
  • PDF (fillable, 125 KB)
  • Word (fillable, 66 KB)
• Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis, HCF 11308 (11/07).
  • PDF (fillable, 186 KB)
  • Word (fillable, 67 KB)

These forms will replace the PA/PDL for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs, HCF 11094 (10/05).

Prescribers are required to complete the forms listed above for PA requests on and after January 16, 2008. For PA requests submitted on or before January 15, 2008, prescribers are required to complete the existing PA/PDL for Cytokine and CAM Antagonist Drugs form.

Refer to Attachments 2 through 11 for copies of the new forms and completion instructions.

Note: Amevive^™, Remicade^®, and Orencia^® will be removed from the cytokine and CAM drug class on January 16, 2008. These drugs will be noncovered pharmacy services under Wisconsin Medicaid; however, they are covered services under Wisconsin Medicaid’s medical benefit. Claims for these drugs may be submitted to Wisconsin Medicaid using “J” codes.

Clinical Criteria for Approval

Prescribers are required to provide clinical documentation on the new PA/PDL for Cytokine and CAM Antagonist Drugs forms so pharmacy providers can submit PA requests to Wisconsin Medicaid. The following explains the clinical criteria requirements.

Ankylosing Spondylitis

Enbrel^® and Humira^® are approved to treat ankylosing spondylitis. For approval of a PA request for these drugs, prescribers are required to indicate “yes” for questions 13, 14, and 15 or 13, 14, and 16 on the PA/PDL for Cytokine and CAM Antagonist Drugs for Ankylosing Spondylitis form.

Clinical criteria for ankylosing spondylitis include the following:

• The recipient has a diagnosis of ankylosing spondylitis.
• The prescription is written by a rheumatologist or through a rheumatology consultation.
• The recipient has moderate to severe axial symptoms of ankylosing spondylitis.
• The recipient has received one or more of the following drugs for at least three consecutive months and failed to achieve an adequate response or a reduction in symptoms or experienced a clinically significant adverse drug reaction:
  • Corticosteroids.
  • Leflunomide.
  • Methotrexate.
  • A nonsteroidal anti-inflammatory drug (NSAID) or cyclo-oxygenase (COX-2) inhibitor drug.
  • Sulfasalazine.

Crohn’s Disease

Humira^® is approved to treat Crohn’s disease. For approval of a PA request for Humira, prescribers are required to indicate “yes” to all clinical criteria questions on the PA/PDL for Cytokine and CAM Antagonist Drugs for Crohn’s Disease form.

Clinical criteria for Crohn’s disease include the following:

• The recipient has a diagnosis of Crohn’s disease.
• The recipient has moderate to severe symptoms of Crohn’s disease.
• The prescription is written by a gastroenterologist or through a gastroenterology consultation.
• The recipient has received two or more of the following drugs and taken each drug for at least three consecutive months and failed to achieve an adequate response or a reduction in symptoms or experienced a clinically significant adverse drug reaction:
  • Azathioprine.
  • Corticosteroids.
  • Methotrexate.
  • Sulfasalazine.
  • 5-aminosalicylic (5-ASA).
  • 6-mercaptopurine (6MP).

Plaque Psoriasis

Enbrel^® and Raptiva^® are approved to treat plaque psoriasis. For approval of a PA request for these drugs, prescribers are required to indicate “yes” for questions 13, 14, 16, and 17, or questions 13, 15, 16, and 17 on the PA/PDL for Cytokine and CAM Antagonist Drugs for Plaque Psoriasis form.

Clinical criteria for plaque psoriasis include the following:

• The recipient has a diagnosis of plaque psoriasis.
• The recipient has moderate to severe symptoms of plaque psoriasis involving greater than or equal to 10 percent or more of his or her body surface area.
• The recipient has a diagnosis of debilitating palmoplantar psoriasis.
• The prescription was written by a dermatologist through a dermatology consultation.
• The recipient has received one or more of the following drugs for at least three consecutive months and failed to achieve an adequate response or a reduction in symptoms or experienced a clinically significant adverse drug reaction:
  • Cyclosporine.
  • Methotrexate.
  • Phototherapy.
  • Soriatane.

Psoriatic Arthritis

Enbrel^® and Humira^® are approved to treat psoriatic arthritis. For approval of a PA request for these drugs, prescribers are required to indicate “yes” for questions 13, 14, 15, and 16, or questions 13, 14, 15, and 17 on the PA/PDL for Cytokine and CAM Antagonist Drugs for Psoriatic Arthritis form.

Clinical criteria for psoriatic arthritis include the following:

• The recipient has a diagnosis of psoriatic arthritis.
• The recipient has moderate to severe symptoms of psoriatic arthritis.
• The prescription is written by a dermatologist or rheumatologist or through a dermatology or rheumatology consultation.
• The recipient has moderate to severe axial symptoms of psoriatic arthritis.
• The recipient has failed to achieve an adequate response or reduction in symptoms with treatment with two or more of the following drugs for at least three consecutive months or experienced a clinically significant adverse drug reaction:
  • Azathioprine.
  • Corticosteroids.
  • Cyclosporine.
  • Hydroxychloroquine.
  • Leflunomide.
  • Methotrexate.
  • An NSAID or COX-2 inhibitor drug.

Rheumatoid Arthritis

Enbrel^®, Humira^®, and Kineret^® are approved to treat rheumatoid arthritis. Enbrel^® is approved to treat polyarticular juvenile rheumatoid arthritis. For approval of a PA request for these drugs, prescribers are required to indicate “yes” for questions 13, 16, and 17 on the PA/PDL for Cytokine and CAM Antagonist Drugs for Rheumatoid Arthritis form. If “no” is indicated in question 13, prescribers are required to indicate “yes” in questions 14, 15, 16, and 17.

Clinical criteria for rheumatoid arthritis include the following:

• The recipient has a diagnosis of polyarticular juvenile rheumatoid arthritis.
• The recipient has a diagnosis of rheumatoid arthritis.
• The recipient has moderate to severe symptoms of rheumatoid arthritis.
• The prescription is written by a rheumatologist or through a rheumatology consultation.
• The recipient has received two or more of the following drugs and taken each drug for at least three consecutive months and failed to achieve an adequate response or a reduction in symptoms or experienced a clinically significant adverse drug reaction:
  • Azathioprine.
  • Corticosteroids.
  • Cyclosporine.
  • Gold sodium thiomalate.
  • Hydroxychloroquine.
  • Leflunomide.
  • Methotrexate.
  • An NSAID or COX-2 inhibitor drug.
  • Penicillamine.
  • Sulfasalazine.

Revised Prior Authorization/Preferred Drug List Form

The PA/PDL for Stimulants and Related Agents, HCF 11097 (fillable PDF, 222 KB) (11/07), will be revised effective for DOS on and after January 16, 2008. Providers may refer to Attachments 12 and 13 for copies of the revised completion instructions and form.

Prescribers are required to complete the revised PA/PDL for Stimulants and Related Agents form for PA requests on and after January 16, 2008. For PA requests submitted on or before January 15, 2008, prescribers are required to complete the existing PA/PDL for Stimulants and Related Agents form.

The wording for the approval criteria for non-preferred stimulants and related agents has been modified to include the following:

• The recipient has a diagnosis of attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD).
• The recipient experienced a treatment failure or a clinically significant adverse drug reaction with the preferred stimulant(s).

The approval criteria for Provigil^® have been revised to include if the recipient has a diagnosis of narcolepsy, obstructive sleep apnea/hypopnea syndrome, or shift work sleep disorder. The rest of the form remains the same.

Discontinued Prior Authorization/Preferred Drug List Forms

Wisconsin Medicaid is discontinuing the following PA/PDL forms for DOS on and after January 3, 2008:

• The PA/PDL for Exubera, HCF 11294 (03/07). (Exubera is no longer available in the marketplace.)
• The PA/PDL for Lamisil, HCF 11180 (09/06). (Terbinafine is a preferred drug on the PDL and requires an appropriate diagnosis code.)

Wisconsin Medicaid will no longer accept these forms after January 3, 2008.

Emergency Medication Dispensing Reminder

Wisconsin Medicaid encourages pharmacy providers to dispense a 14-day emergency supply of a medication when they determine it is medically necessary or an emergency. An emergency medication supply may be dispensed if a recipient receives a prescription for a drug with any type of restriction and the physician cannot be reached to obtain a new prescription or the appropriate documentation to override the restriction. The emergency medication dispensing policy overrides drug restriction policies and all PA polices including the PDL, brand medically necessary, and diagnosis-restriction policies; however, other policies, such as recipient eligibility and noncovered services still apply. Medications dispensed in an emergency do not require PA.

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim form, HCF 13072 (fillable PDF, 82 KB) (06/03), with a Pharmacy Special Handling Request form, HCF 13074 (fillable PDF, 162 KB) (06/06), indicating the nature of the emergency. Providers should mail completed Noncompound Drug Claim and Pharmacy Special Handling Request forms to the address on the Pharmacy Special Handling Request form. Providers may also fax these forms to Wisconsin Medicaid and (608) 221-8616.

Providers may refer to the February 2007 Update (2007-14), titled “Emergency Medication Dispensing,” for additional information.

Wisconsin Medicaid and SeniorCare Preferred Drug Lists Available on ePocrates

Wisconsin Medicaid and SeniorCare providers may access the PDL using their personal digital assistants (PDAs) or personal computers through ePocrates. ePocrates’ products provide clinical reference information specifically for health care providers at the point of care. Prescribers and pharmacy providers who use PDAs may also subscribe and download the PDL by accessing the ePocrates Web site at www.epocrates.com/.

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 at dhs.wisconsin.gov/medicaid/pharmacy/index.htm.

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 — Medicaid Provider Letter (PDF, 40 KB)

Attachment 2 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Completion Instructions (PDF, 22 KB)

Attachment 3 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis (fillable PDF, 323 KB)  |  Word (fillable, 63 KB)

Attachment 4 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease Completion Instructions (PDF, 22 KB)

Attachment 5 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease (fillable PDF, 244 KB)  |  Word (fillable, 64 KB)

Attachment 6 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis Completion Instructions

Attachment 7 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis (fillable PDF, 353 KB)  |  Word (fillable, 60 KB)

Attachment 8 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriatic Arthritis Completion Instructions (PDF, 22 KB)

Attachment 9 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriatic Arthritis (fillable PDF, 125 KB)  |  Word (66 KB)

Attachment 10 — Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis Completion Instructions (PDF, 22 KB)

Attachment 11 — Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (fillable PDF, 186 KB)  |  Word (67 KB)

Attachment 12 — Prior Authorization/Preferred Drug List (PA/PDL) for Stimulants and Related Agents Completion Instructions (PDF, 24 KB)

Attachment 13 — Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents (fillable PDF, 222 KB)  |  Word (fillable,108 KB)