Effective for dates of service on and after July 10, 2006, Wisconsin Medicaid will establish quantity limits on the antimigraine, triptans. The following are included in the antimigraine, triptans drug class:

• Amerge tablets.
• Axert tablets.
• Frova tablets.
• Imitrex tablets, Imitrex nasal spray, and Imitrex syringes.
• Maxalt tablets and Maxalt MLT.
• Relpax tablets.
• Zomig tablets, Zomig nasal spray, and Zomig ZMT.

Amerge, Imitrex, and Maxalt are the preferred drugs. Providers are reminded that recipients must experience treatment failure(s) or a contraindication(s) to a preferred drug(s) before a non-preferred drug may be prescribed.

Quantity Limits

Quantities of triptans are limited to the following:

• Eighteen tablets every month, regardless of the drug dispensed.
• Eight syringes (four boxes) every month, regardless of the drug dispensed.
• Six nasal sprays (one box) every month, regardless of the drug dispensed.

For example, a recipient will not be allowed to receive more than 18 tablets of any one triptan or a combination of triptans. However, the recipient may receive a combination of tablets, nasal sprays, and syringes for triptans if medically necessary.

Recipients are limited to the quantities indicated in this Wisconsin Medicaid and BadgerCare Update, regardless of a drug’s preferred or non-preferred status on the Preferred Drug List.

Claim Submission

When a claim is submitted with a quantity that exceeds the limit, providers will receive the following:

• Explanation of Benefits (EOB) code 485: “Quantity limits exceeded.”
• National Council for Prescription Drug Programs (NCPDP) reject code 76: “Plan limitations exceeded.”

The pharmacy provider should contact the prescriber to determine that it is medically necessary for a recipient to exceed the quantity limits. If this is necessary, the pharmacy provider is required to complete the Noncompound Drug Claim form, HCF 13072 (fillable PDF, 82 KB) (Rev. 06/03), and a Pharmacy Special Handling Request form, HCF 13074 (fillable PDF, 23 KB) (Rev. 06/06), explaining the medical necessity to exceed the set quantity limits. Refer to Attachments 1, 2, 3, and 4 of this Update for these forms and completion instructions.

Providers should submit these claims on paper using the Noncompound Drug Claim and the Pharmacy Special Handling Request when EOB code 485 is received. On the Pharmacy Special Handling Request, providers should indicate the following:

• Complete directions for use. (“As needed” or “PRN” are not sufficient.)
• The maximum triptan dose the prescriber has established by day, week, or month.
• The migraine prophylactic medication the recipient is taking. Providers are required to specify the drug name and strength, directions for use, and compliance.
• Other abortive analgesic headache medicines the recipient is taking. Providers are required to specify the drug name and strength, quantity, directions for use, and how frequently the medication is being filled.
• Pharmacy providers should also include clinical information from the prescriber regarding the frequency of the headaches, and either why prophylactic treatment is not being used or why prophylactic treatment has been unsuccessful in reducing the headache frequency.

Prior Authorization

Providers may not exceed quantity limits for triptans even if a prior authorization (PA) request for a triptan has been previously approved.

Pharmaceutical Care Expansion

Effective immediately, Wisconsin Medicaid is allowing pharmacy providers to receive a Pharmaceutical Care (PC) dispensing fee in the following situations:

• If the pharmacy provider contacts the prescriber and a prescription is changed from a non-preferred drug to a preferred drug.
• If “Brand Medically Necessary” is indicated on a prescription and the pharmacy provider contacts the prescriber to change the drug to its generic equivalent.

Providers should indicate therapeutic substitution (“TS”) on claims to obtain the PC dispensing fee when these situations occur. Providers should also indicate the appropriate action code, result code, and level of effort on these claims.

Refer to the Drug Utilization Review and Pharmaceutical Care section of the Pharmacy Handbook for additional information about PC dispensing fees and claim submission procedures.

Documentation Requirements

The documentation requirements for the “TS” PC dispensing fee have been simplified. Pharmacy providers are required to document the following in the recipient’s file or on the prescription when a “TS” PC dispensing fee is submitted to Wisconsin Medicaid:

• The date the prescriber was contacted.
• The change to the prescription.
• The name of the pharmacy provider who made the contact.
• The name of the person in the prescriber’s office who authorized the change to the prescription.

Emergency Medication Dispensing Reminder

An emergency medication supply may be dispensed in situations where the pharmacy provider or prescriber deem it is medically necessary.

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim form (fillable PDF, 82 KB) with a Pharmacy Special Handling Request form (fillable PDF, 23 KB), indicating the nature of the emergency. Providers should mail completed Noncompound Drug Claim and Pharmacy Special Handling Request forms as indicated on the Pharmacy Special Handling Request form. Medications dispensed in an emergency situation do not require PA.

Changes have been made to the Pharmacy Special Handling Request form. The revised Pharmacy Special Handling Request and completion instructions are located in Attachments 3 and 4 for photocopying and also may be downloaded and printed from the Medicaid Web site.

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 — Noncompound Drug Claim Completion Instructions (PDF, 30 KB)
Attachment 2 — Noncompound Drug Claim (fillable PDF, 82 KB)
Attachment 3 — Pharmacy Special Handling Request Completion Instructions (PDF, 18 KB)
Attachment 4 — Pharmacy Special Handling Request (fillable PDF, 23 KB)