The following drugs are diagnosis restricted through Wisconsin Medicaid. These drugs do not require prior authorization unless prescribed outside diagnoses listed in the table in Attachment 7 of this Wisconsin Medicaid and BadgerCare Update.

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

Alphabetical Listing of Diagnosis-Restricted Drugs
Generic Name	Brand Name
Alglucerase	Ceredase, Cedezyme
Amphetamines	Adderall, Adderall XR, Amphetamine Salts
Atomoxetine HCl	Strattera
Botulinum Toxin Type A	Botox
Botulinum Toxin Type B	Myobloc
Bupropion	Zyban
Darbopoetin Alfa in Albumin Solution	Aranesp
Dexmethylphenidate	Focalin
Dextroamphetamines	Dexedrine, Dextrostat, Dextroamphetamine
Epoetin	Epogen, Procrit
Filgrastim	Neupogen
Interferon Alfa 2A	Roferon-A
Interferon Alfa 2B	Intron A
Interferon Alfa 2B/Ribavirin	Rebetron
Interferon Alfa N3	Alferon N
Interferon Alfacon 1	Infergen
Interferon Beta 1A	Avonex
Interferon Beta 1B	Betaseron
Interferon Beta 1A, Albumin	Rebif
Interferon Gamma 1B	Actimmune
Lansoprazole	Prevacid Suspension
Lansoprazole/Antibiotic	Prevpac
Legend Prenatal Vitamins
Legend Renal Care Vitamins	Renax, Diatx, Diatx FE, Nephrovite, Dialyvite
Methamphetamines	Desoxyn
Methylphenidate	Concerta, Metadate, Ritalin, Ritalin LA, Methylin, Methylin ER, Methylphenidate, Methylphenidate ER
Miglustat	Zavesca
Misoprostol	Cytotec
Modafinil	Provigil
Mupirocin	Bactroban 2 percent
Muromonab CD3	Orthoclone OKT-3
Nicotine	Prostep, Habitrol
Omeprazole	Prilosec OTC 20 mg tablets
Pegfilgrastim	Neulasta
Peginterferon Alfa-2A	Pegasys
Peginterferon Alfa-2B	Peg-Intron
Pemoline	Cylert, Pemoline
Ribavirin	Copegus, Rebetol
Sargramostim	Leukine

Attachment 1: Brand Medically Necessary Drugs That Require Prior Authorization
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 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)

Back to the beginning of this Update