Attachment 1: Brand Medically Necessary Drugs That Require Prior Authorization - August 2004 Wisconsin Medicaid and BadgerCare Update 2004-62

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The following table lists brand medically necessary drugs that require prior authorization (PA). When a brand medically necessary prescription is written, prescribers are required to submit a completed MedWatch Voluntary Reporting form, (PDF, 53 KB) which can be located at www.fda.gov/medwatch/, with the prescription to the pharmacy.

Most drug strengths, including long-acting drugs, are included as brand medically necessary drugs that require PA in this attachment. For questions, providers can refer to the Wisconsin Medicaid Maximum Allowable Cost list.

Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically. All drugs listed in this table are registered or trademarked by the manufacturer.

Brand Medically Necessary Drugs That Require Prior Authorization
Accuretic	Diprolene^*	Minocin	Revia
Accutane	Diprosone^*	Modicon	Rheumatrex
Achromycin	Ditropan	Moduretic	Rhythmol
Actigall	Diuril	Monoket	Rifadin^*
Adalat CC	Dolobid	Monopril	Ritalin
Adderall	Doryx^*	Motrin	Robaxin
Adipex-P	Duricef^**	MS Contin	Rocaltrol
Aldactazide	Dyazide	Mucomyst	Sectral^**
Aldactone	EC-Naprosyn	Mycelex-G	Selsun Lotion
Aldoril	E.E.S.	Mycolog II	Septra
Alphagan	Elavil	Mycostatin	Serax
Alupent	Elixophyllin^*	Mydriacyl	Serzone
Amikin	Elocon*	Mysoline	Silvadene^**
Amoxil	Enduron	Nalfon	Sinemet
Anafranil	Eryc^*	Naprosyn	Sinequan
Anaprox	Erycette	Nasalide	Soma
Ansaid	Erygel^**	Navane	Soma Compound
Antivert	Eryped	Nebcin	Spectazole
Apresoline	Ery-tab	Neoral	Stadol
Aristocort^*	Esgic-Plus^*	Neosporin	Staticin
Aristocort A^*	Eskalith	NitroDur^*	Stelazine
Artane	Estrace^**	Nitro-Stat	Symmetrel
Atarax	Eulexin^*	Nizoral	Synalar^*
Ativan	Feldene	Nolvadex	Tagamet
Atromid-S	Fioricet	Norflex CR^*	Tambocor^*
Atrovent	Fiorinal	Norgesic^*	Tapazole
Augmentin	Flagyl	Norinyl	Taxol
Aventyl^*	Flexeril	Normodyne^*	Tegretol
Axid	Florinef	Norpace	Temovate
Azulfidine	Floxin	Norpramin^*	Tenex^*
Bactocill	Flumadine^*	Ocuflox	Tenoretic
Bactrim	FML	Ocupress	Tenormin
Bancap HC^*	Fulvicin P/G^*	Ogen	Tenuate^*
Benadryl	Fulvicin U/F^*	Optipranolol	Terazol
Bentyl^*	Furacin	Ortho-Novum	Tessalon Perles^*
Betagan	Garamycin^*	Orudis	Theo-Dur^*
Betapace	Glucophage	Oruvail	Thorazine
Blocadren	Glucotrol	Oxycontin	Tiazac^*
Brethine	Glucovance	Oxyir	Ticlid
Bumex	Glynase Prestab	Pamelor	Timoptic
Buspar	Halcion	Parafon Forte DSC	Timoptic-XE
Butisol Sodium Elixir	Haldol	Parlodel	Tobrex
Calan	Haldol Decanoate	Pediazole	Tofranil
Calciferol	Hydrea	Pentam^*	Tolectin
Capoten	Hydrodiuril	Pepcid	Tolinase
Capozide	Hytone^*	Percocet	Topicort^**
Carafate^**	Hytrin	Percodan	Transderm Nitro
Cardene	Imdur^*	Percolone	Tranxene^**
Cardizem^**	Imuran	Periactin	Trental^*
Cardura	Inderal	Peridex^*	Tricor
Cataflam	Inderide	Periostat	Tridesilon
Catapres	Indocin	Permax	Trilafon^*
Ceclor	Inflamase Forte	Persantine	T-Stat
Ceftin^**	Inflamase Mild	Phenergan	Tylenol with Codeine
Chloromycetin	Intal Nebulizer Solution^*	Phenergan with Codeine	Tylox
Chloroptic	Isoptin	Phenergan with DM	Ultram
Cleocin	Isordil	Plaquenil^*	Univasc
Cleocin T	K-Dur^*	Polaramine^*	Vancocin HCl
Clinoril	Keflex	Polysporin	Vaseretic
Clozaril^***	Kenalog	Polytrim	Vasotec
Cogentin	Kenalog with Orabase	Pred Forte	Velosef
Compazine	Kerlone^**	Prelone^*	Ventolin
Copegus	Klonopin	Prilosec	Vepesid
Cordarone	Lac Hydrin	Primacor^*	Verelan
Corgard	Lanoxin	Principen	Vibramycin
Cortef	Lasix^*	Prinivil	Vibra-Tabs
Cortisporin	Lidex^*	Prinzide	Vicodin
Coumadin	Limbitrol	Procardia	Vicoprofen
Cutivate	Lioresal	Prolixin	Vistaril
Cyclogyl	Lodine	Prolixin Decanoate	Voltaren
Cylert	Lomotil	Proloprim	Wellbutrin
Cytotec	Loniten	Pronestyl	Westcort
Dalmane	Luvox	Propine	Xanax
Danocrine^*	Macrobid	Prosom	Xylocaine
Darvocet N 100	Macrodantin	Proventil^*	Xylocaine Viscous
Daypro	Maxitrol	Provera	Zanaflex
DDAVP^*	Maxzide	Psorcon^*	Zantac
Decadron	Medrol	Questran	Zaroxolyn
Deltasone	Megace	Questran Lite	Zebeta
Demadex	Mellaril	Quinaglute	Zestoretic
Depakene	Mevacor	Rebetol^*	Zestril
Desyrel	Mexitil	Reglan	Ziac
Dexedrine	Micro K^*	Relafen	Zinacef
Diabinese	Micronase	Remeron	Zovirax
Diamox	Midamor	Remeron Soltab	Zyloprim
Dilacor XR^**	Miltown	Restoril
Dilantin Kapseal	Minipress	Retin-A

^*	This drug does not have a signed rebate agreement on file with the Department of Health and Family Services (DHFS). Wisconsin SeniorCare will not cover a drug that does not have a signed SeniorCare rebate agreement between the manufacturer and the DHFS. Providers should note that drugs without signed rebate agreements for SeniorCare participants in Levels 2b and 3 will not be covered; however, these drugs may be covered for participants in Levels 1 and 2a.
^**	This drug has a signed rebate agreement with specific manufacturers. Providers may refer to Appendix 1 of the Pharmacy Data Tables section of the Pharmacy Handbook for a list of manufacturers that do not have signed SeniorCare rebate agreements. Providers may also call Provider Services at (800) 947-9627 or (608) 221-9883 to obtain a list of manufacturers with signed rebate agreements, or they can refer to the SeniorCare section of the Pharmacy Handbook for more information on drug rebate agreements.
^***	Refer to the "Prior Authorization for Brand Name Clozaril^® " section of this Wisconsin Medicaid and BadgerCare Update for more information on obtaining PA for brand name Clozaril^® .

Attachment 2: Brand Medically Necessary Prior Authorization Documentation
Attachment 3: MedWatch Reporting Form (FDA Web site) (PDF, 53 KB)
Attachment 4: Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) Drugs
Attachment 5: Drug Products Requiring Paper Prior Authorization
Attachment 6: Diagnosis-Restricted Drugs (Organized by Generic Drug Name)
Attachment 7: Diagnosis-Restricted Drugs (Organized by Diagnosis Code Description)
Attachment 8: Covered Over-the-Counter Drugs
Attachment 9: Noncovered Drugs
Attachment 10: Age- and Gender-Restricted Drugs
Attachment 11: Covered Over-the-Counter Drugs for HealthCheck "Other Services"
Attachment 12: Comparison of Wisconsin Medicaid and Wisconsin SeniorCare Policies
Attachment 13: Obsolete 1/1/05: STAT-PA Drug Worksheet for Brand Name Clozaril^® — Use Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) (fillable PDF, 225 KB) | Instructions (PDF, 71 KB)

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