This Wisconsin Medicaid and BadgerCare Update reminds providers about the emergency medication dispensing policy that allows providers to dispense up to a 14-day supply of a drug in situations where the pharmacy provider or prescriber deem it medically necessary. This policy overrides drug restriction policies and all prior authorization (PA) policies including the Preferred Drug List, brand medically necessary, and diagnosis restriction policies; however, other policies, such as recipient eligibility and noncovered services policies still apply. The information in this Update applies to Wisconsin Medicaid recipients and SeniorCare participants.

Providers may dispense up to a 14-day supply of a medication under the emergency medication dispensing policy. When subsequent refills are dispensed, all current drug restriction policies and PA policies apply.

Wisconsin Medicaid encourages pharmacy providers to dispense an emergency supply of a medication when they determine it is medically necessary or an emergency. An emergency medication supply may be dispensed if a recipient receives a prescription for a drug with any type of restriction, including a diagnosis restriction, PA requirement, or age or sex-restriction, and the physician cannot be reached to obtain the appropriate documentation to override the restriction.

Claim Submission

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim form, HCF 13072 (fillable PDF, 82 KB) (Rev. 06/03), with a Pharmacy Special Handling Request form, HCF 13074 (fillable PDF, 162 KB) (Rev. 06/06), 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. Providers may also fax these forms to Wisconsin Medicaid at (608) 221-8616.

Changes were made to the Pharmacy Special Handling Request form to allow providers to check that an emergency supply was dispensed. The Pharmacy Special Handling Request form and completion instructions are located in Attachment 1 (PDF, 30 KB) and Attachment 2 (fillable PDF, 162 KB) of this Update for photocopying and may also be downloaded and printed from the Medicaid Web site. The Noncompound Drug Claim completion instructions and form are included in Attachment 3 (PDF, 18 KB) and Attachment 4 (fillable PDF, 82 KB).

Completing Claim Forms Correctly

Providers are required to correctly complete the Pharmacy Special Handling Request form and the Noncompound Drug Claim form to receive the appropriate reimbursement for an emergency medication supply. Wisconsin Medicaid is committed to reimbursing providers for emergency medications as long as claims are properly completed and submitted with a Pharmacy Special Handling Request form.

Claims are denied when a provider does not complete the “UD” field. Providers are reminded to complete Element 17 (“UD”) on the Noncompound Drug Claim form with the appropriate unit dose value. Unit dose values may be found in the Noncompound Drug Claim Completion Instructions, HCF 13072A (Rev. 06/03).

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 — Pharmacy Special Handling Request Completion Instructions (PDF, 30 KB)
Attachment 2 — Pharmacy Special Handling Request (fillable PDF, 162 KB) | Word (fillable, 37 KB)
Attachment 3 — Noncompound Drug Claim Completion Instructions (PDF, 30 KB)
Attachment 4 — Noncompound Drug Claim (fillable PDF, 82 KB)