BadgerCare Plus has added three new classes to the Preferred Drug List (PDL) and made changes to previously reviewed classes. Changes indicated on this BadgerCare Plus Update apply to the following:

• BadgerCare Plus Standard Plan members.
• SeniorCare members.
• Managed care members who were transitioned to fee-for-service effective for dates of service (DOS) on and after February 1, 2008.

Changes indicated in this Update do not apply to BadgerCare Plus Benchmark Plan members. As a reminder, certain generic drugs and a limited number of over-the-counter drugs are covered for Benchmark Plan members.

Providers are reminded that, as a result of the Department of Health and Family Services pharmacy consolidation, pharmacy services and some drug-related supplies for managed care members are reimbursed by fee-for-service. For more information about the pharmacy consolidation, providers may refer to the January 2008 Update (2008-07), titled “Pharmacy Consolidation for Wisconsin Medicaid and BadgerCare Plus Managed Care Members.”

New Classes Added to the Preferred Drug List

BadgerCare Plus will add the drug classes listed below to the PDL effective for DOS on and after April 2, 2008. Drugs listed in the classes below are preferred drugs.

BadgerCare Plus will begin accepting prior authorization (PA) requests for non-preferred drugs in these classes beginning March 24, 2008. Prescribers are required to complete and submit to a pharmacy provider the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, HCF 11075 (12/06), for non-preferred drugs in these classes.

Antibiotics, GI Alinia metronidazole neomycin Tindamax Vancocin HCl Impetigo, Topical Antibiotics* mupirocin ointment *Quantity limits and diagnosis restrictions apply.

Skeletal Muscle Relaxants baclofen carisoprodol, compound chlorzoxazone cyclobenzaprine dantrolene sodium methocarbamol tizanidine

Skeletal Muscle Relaxants Drug Class

Effective for DOS on and after July 1, 2008, carisoprodol and the carisoprodol compound will be non-preferred skeletal muscle relaxant drugs that will require PA. Prescribers may either change a member’s prescription to a preferred drug or request PA for carisoprodol or the carisoprodol compound if it is medically necessary. Prescribers with members taking carisoprodol or the carisoprodol compound will receive a letter from BadgerCare Plus describing the change in status of the drugs and the provider’s responsibility to change the member to a preferred drug or obtain PA.

If it is medically necessary for a member to remain on carisoprodol or the carisoprodol compound, prescribers are required to complete the PA/PDL Exemption Request form and submit it to the pharmacy where the prescription will be filled. Pharmacy providers are required to submit the PA request to BadgerCare Plus using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or on paper.

Reviewed Classes on the Preferred Drug List

BadgerCare Plus has reviewed the following PDL drug classes. Preferred drugs are listed below. Changes to the PDL are effective for DOS on and after April 2, 2008. Current, approved PAs will be honored until their expiration date or until services have been exhausted.

Acne Agents, Topical Azelex benzoyl peroxide Clinac BPO clindamycin phosphate erythromycin Retin-A Micro Tazorac tretinoin BPH Treatments Avodart doxazosin finasteride Flomax terazosin Uroxatral Analgesics, Narcotics, Long Acting fentanyl transdermal patches Kadian methadone morphine ER Analgesics, Narcotics, Short Acting acetaminophen/codeine aspirin/codeine butalbital/apap/codeine/caffeine codeine dihyrocodeine/apap/caffeine hydrocodone/apap hydrocodone/ibuprofen hydromorphone levorphanol morphine oxycodone oxycodone/apap, aspirin oxycodone/ibuprofen propoxyphene HCl, apap tramadol Angiotensin Modulators Avalide, Avapro benazepril, HCTZ Benicar, HCT captopril, HCTZ Cozaar, Hyzaar Diovan, HCT enalapril, HCTZ fosinopril, HCTZ lisinopril, HCTZ Micardis, HCT Note: BadgerCare Plus has combined the angiotensin modulators and angiotensin receptor blockers classes into a new PDL class, titled "Angiotensin Modulators." Angiotensin Modulators/Calcium Channel Blocker Combinations amlodipine/benazepril Exforge Tarka Anticoagulants, Injectables Arixtra Fragmin Lovenox Anticonvulsants carbamazepine Carbatrol Celontin clonazepam Depakote, ER, sprinkle Diastat ethosuximide Equetro Felbatol gabapentin Gabitril Keppra Lamictal Lyrica mephobarbital oxcarbazepine Peganone phenobarbital phenytoin primidone Topamax valproic acid zonisamide Antihistamines, Nonsedating certrizine over-the-counter 5mg and 10mg tablets loratadine tablet, syrup, loratadine-D Antimigraine, Triptans* Imitrex (oral, nasal, and subcutaneous) Maxalt, MLT Relpax *Quantity limits apply. Beta Blockers acebutolol atenolol betaxolol bisoprolol carvedilol labetalol metoprolol nadolol pindolol propranolol sotalol timolol

Bladder Relaxant Preparations Detrol LA Enablex oxybutynin, ER Oxytrol Sanctura, XR VESIcare Calcium Channel Blocking Agents amlodipine Cardizem LA diltiazem felodipine ER nicardipine nifedipine, ER nimodipine verapamil, ER, SR Erythropoiesis Stimulating Proteins Aranesp Procrit Growth Hormone Drugs Genotropin† Nutropin, AQ† Saizen† Tev-Tropin† †Preferred drugs that require clinical PA. Hepatitis C Agents Pegasys Peg-Intron, Redipen ribavirin Hypoglycemics, Meglitinides Starlix Hypoglycemics, Thiazolidinediones Actoplus Met Actos Avandamet Avandaryl Avandia Duetact Lipotropics, Bile Acid Sequestrants cholestyramine colestipol Lipotropics, Fibric Acids fenofibrate gemfibrozil Tricor Lipotropics, Other Niaspan Zetia Lipotropics, Statins Lescol, XL Lipitor lovastatin pravastatin simvastatin Vytorin Multiple Sclerosis Agents Avonex Betaseron Copaxone Rebif Otics, Fluoroquinolones Ciprodex ofloxacin Phosphate Binders Fosrenol Phoslo Renagel Proton Pump Inhibitors Nexium* Prevacid (capsules, SoluTab, suspension)* Prilosec OTC* *Diagnosis restricted drug. Sedative Hypnotics chloral hydrate estazolam flurazepam Rozerem temazepam zolpidem Ulcerative Colitis Agents Asacol Canasa Colazal mesalamine sulfasalazine

Sedative Hypnotics Drug Class

As a result of safety concerns, the Wisconsin Medicaid Pharmacy Prior Authorization Advisory Committee has recommended that triazolam be a non-preferred drug. Effective for DOS on and after April 2, 2008, triazolam will be non-preferred and will require PA.

Grandfathering

Effective for DOS on and after April 2, 2008, BadgerCare Plus will grandfather prescriptions for Norditropin^® for managed care members who transitioned to BadgerCare Plus on February 1, 2008. These members may remain on Norditropin^® until October 1, 2008, without PA.

Revised Prior Authorization/Preferred Drug List Forms

BadgerCare Plus has revised the following PA/PDL forms:

• The Prior Authorization/Preferred Drug List (PA/PDL) for Elidel^® and Protopic^®, HCF 11303 (03/08).
• The Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs, HCF 11078 (03/08).

Refer to Attachments 1 through 4 of this Update for copies of the PA/PDL for Elidel^® and Protopic^® and the PA/PDL for PPI Drugs completion instructions and forms.

Prior Authorization Request Submissions

As a reminder, PA is always required for non-preferred drugs and future refills of newly designated non-preferred drugs. Prescribers are required to complete and sign the appropriate PA/PDL form and submit it to the pharmacy provider where the prescription will be filled. Pharmacy 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. To access the STAT-PA system, providers may call (800) 947-1197 or (608) 221-2096.

Paper

If a PA request must be submitted on paper, the pharmacy provider is required to complete, sign, and date a Prior Authorization Request Form, HCF 11018 (10/03), and submit it to BadgerCare Plus with the appropriate PA/PDL form that was completed by the prescriber.

Reminders

BadgerCare Plus and SeniorCare Preferred Drug Lists Available on ePocrates

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

Emergency Medication Dispensing Reminder

BadgerCare Plus 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 member 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 policies including the PDL, brand medically necessary, and diagnosis-restriction policies; however, other policies, such as member 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 (06/03), with a Pharmacy Special Handling Request form, HCF 13074 (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 BadgerCare Plus at (608) 221-8616.

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

For More Information

Providers may refer to the Data Tables on the Pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/index.htm for a list of drugs where quantity limits apply and diagnoses are restricted.

Information Regarding Managed Care

This Update contains fee-for-service policy and applies to services members receive on a fee-for-service basis only. Pharmacy services for members enrolled in the Program of All-Inclusive Care for the Elderly (PACE) and the Family Care Partnership are provided by the member’s managed care organization. Managed care organizations must provide at least the same benefits as those provided under fee-for-service.

Attachment 1 — Prior Authorization/Preferred Drug List (PA/PDL) for Elidel^® and Protopic^® Completion Instructions
Attachment 2 — Prior Authorization/Preferred Drug List (PA/PDL) for Elidel^® and Protopic^®
Attachment 3 — Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions
Attachment 4 — Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs