Attachment 7: Diagnosis-Restricted Drugs (Organized by Diagnosis Code Description) - August 2004 Wisconsin Medicaid and BadgerCare Update 2004-62

Attachment 7: Diagnosis-Restricted Drugs

(Organized by Diagnosis Code Description)

PDF (176 KB)

The following table lists diagnosis-restricted drug categories and the corresponding diagnosis codes and disease descriptions. When a prescription is written for a diagnosis listed in this attachment, prior authorization (PA) is not required. For uses outside the listed diagnoses, PA is required. Submission of peer-reviewed medical literature to support the proven efficacy of the requested use of the drug is also required.

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.

Diagnosis Code Description	Diagnosis Code	Generic Drug Name	Brand Name
Non-Steroidal Anti-Inflammatory Drug (NSAID)-induced gastric ulcer NSAID-induced duodenal ulcer	E9356	Omeprazole	Prilosec OTC 20 mg tablets
H. Pylori infection	04186
Zollinger-Ellison syndrome	2515
Erosive esophagitis	53019
Gastroesophageal reflux	53081
Gastric hypersecretory conditions	5368
NSAID-induced gastric ulcer NSAID-induced duodenal ulcer	E9356	Lansoprazole	Prevacid Suspension
H. Pylori infection	04186
Zollinger-Ellison syndrome	2515
Erosive esophagitis	53019
Gastroesophageal reflux	53081
Gastric hypersecretory conditions	5368
NSAID-induced gastric ulcer NSAID-induced duodenal ulcer	E9356	Misoprostol	Cytotec
H. Pylori infection	04186	Lansoprazole/ Antibiotic	Prevpac
Gaucher’s Disease	2727	Alglucerase	Ceredase, Cedezyme
Gaucher’s Disease	2727	Miglustat	Zavesca
Anemia from Acquired Immune Deficiency Syndrome (AIDS)	042	Epoetin	Epogen, Procrit
Renal failure	585
Malignancy	2399
Renal failure	585	Darbopoetin Alfa in Albumin Solution	Aranesp
Chronic hepatitis C without hepatic coma	07054	Interferon Alfa 2A	Roferon-A
Malignant melanoma	1729
Kaposi’s sarcoma	1760-1769
Hairy cell leukemia	2024
Non-Hodgkin’s lymphoma	2028
Multiple myeloma	2030
Chronic myelocytic leukemia	2051
Bladder carcinoma	2337
Renal cell carcinoma	2339
Chronic hepatitis C without hepatic coma	07054	Interferon Alfa 2B	Intron A
Condylomata acuminata	07811
Malignant melanoma	1729
Kaposi’s sarcoma	1760-1769
Hairy cell leukemia	2024
Non-Hodgkin’s lymphoma	2028
Multiple myeloma	2030
Bladder carcinoma	2337
Renal cell carcinoma	2339
Chronic hepatitis C without hepatic coma	07054	Peginterferon Alfa-2A	Pegasys
Chronic hepatitis C without hepatic coma	07054	Peginterferon Alfa-2B	Peg-Intron
Condylomata acuminata	07811	Interferon Alfa N3	Alferon N
Chronic granulomatous disease	2881	Interferon Gamma 1B	Actimmune
Osteopetrosis	75652	Interferon Gamma 1B	Actimmune
Chronic hepatitis C without hepatic coma	07054	Interferon Alfacon 1	Infergen
Chronic hepatitis C without hepatic coma	07054	Interferon Alfa 2B/Ribavirin	Rebetron
Chronic hepatitis C without hepatic coma	07054	Ribavirin	Copegus
Chronic hepatitis C without hepatic coma	07054	Ribavirin	Rebetol
Multiple sclerosis	340	Interferon Beta 1A	Avonex
Multiple sclerosis	340	Interferon Beta 1B	Betaseron
Multiple sclerosis	340	Interferon Beta 1A, Albumin	Rebif
Agranulocytosis/Neutropenia	2880	Filgrastim	Neupogen
Agranulocytosis/Neutropenia	2880	Pegfilgrastim	Neulasta
Myeloid leukemia	205	Sargramostim	Leukine
Impetigo	684	Mupirocin	Bactroban 2 percent
Organ transplant rejection	9968	Muromonab CD3	Orthoclone OKT-3
Nicotine dependence treatment	3051	Bupropion	Zyban
Nicotine dependence treatment	3051	Nicotine	Prostep, Habitrol
Blepharospasm	33381	Botulinum Toxin Type A	Botox
Spasmodic Torticollis	33383
Strabismus	3780-37887
Spasmodic Torticollis	33383	Botulinum Toxin Type B	Myobloc
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Methylphenidate	Concerta Metadate Ritalin Ritalin LA Methylin Methylin ER Methylphenidate Methylphenidate ER
Attention Deficit Disorder without mention of hyperactivity	31400
Attention Deficit Disorder with hyperactivity (ADHD)	31401
Narcolepsy and Cataplexy	347
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Dexmethylphenidate	Focalin
Attention Deficit Disorder without mention of hyperactivity	31400
ADHD	31401
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Dextroamphetamines	Dexedrine Dextrostat Dextroamphetamine
Attention Deficit Disorder without mention of hyperactivity	31400
ADHD	31401
Narcolepsy and Cataplexy	347
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Amphetamines	Adderall Adderall XR Amphetamine Salts
Attention Deficit Disorder without mention of hyperactivity	31400
ADHD	31401
Narcolepsy and Cataplexy	347
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Methamphetamines	Desoxyn
Attention Deficit Disorder without mention of hyperactivity	31400
ADHD	31401
Obesity	278
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Atomoxetine HCl	Strattera
Attention Deficit Disorder without mention of hyperactivity	31400
ADHD	31401
Narcolepsy and Cataplexy	347	Modafinil	Provigil
Obstructive sleep apnea, hypopnea, and shift-work sleep disorder	78057	Modafinil	Provigil
Hyperkinetic syndrome of childhood — Attention Deficit Disorder	314	Pemoline	Cylert Pemoline
Attention Deficit Disorder without mention of hyperactivity	31400
ADHD	31401
Anemia in end-stage renal disease	28521	Legend Renal Care Vitamins	Renax Diatx Diatx FE Nephrovite Dialyvite
Chronic renal failure	585
Disorders resulting from impaired renal function	588
Unspecified disorder resulting from impaired renal function	5889
Normal pregnancy	V22-V222	Legend Prenatal Vitamins
High-risk pregnancy	V23-V239
Lactating	V241

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 6: Diagnosis-Restricted Drugs (Organized by Generic Drug Name)
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)