The policies in the Pharmacy Handbook govern services provided within the scope of the profession’s practice as defined in the Wisconsin Statutes and the Wisconsin Administrative Code.
For Wisconsin Medicaid certification for dispensing pharmaceuticals, the provider must currently be licensed by the Wisconsin Department of Regulation and Licensing in one or both of the following ways:
For general information on applying for Wisconsin Medicaid certification, please refer to the Provider Certification section of the All-Provider Handbook.
Pharmacies may dispense disposable medical supplies (DMS) and durable medical equipment (DME) in addition to drugs without separate certification. Refer to the DME Handbook as well as the DME and DMS Indices for all DME and DMS covered services, prior authorization (PA) guidelines, and billing instructions. In addition to receiving publications for pharmacy services, Medicaid-certified pharmacy providers automatically receive all publications regarding DME and DMS services.
Pharmacies that change ownership or locations are required to notify Wisconsin Medicaid’s Provider Maintenance Unit of all changes, including a new license number. (Refer to the Provider Certification section of the All-Provider Handbook for further information on change of address and status.) When pharmacies have multiple locations, each location with a unique license number must have its own Medicaid certification and provider number.
Dispensing physicians, as part of their usual and customary professional services, may dispense drug products to their patients.
Dispensing physicians must comply with all the related limitations and service requirements in this handbook.
Detailed information about the responsibilities as a Medicaid-certified provider can be found in the Provider Rights and Responsibilities section of the All-Provider Handbook. Refer to that section for information about the following:
|
Clarifying the Terms "Dispensing Physician," "Pharmacist," and "Pharmacy Provider"
|
Wisconsin Medicaid recipients receive a Medicaid ID card upon initial enrollment into Wisconsin Medicaid.
Medicaid ID cards may be in any of the following formats:
The Forward card is a plastic magnetic stripe identification card that enables providers to verify eligibility.
When green temporary paper cards or beige presumptive eligibility paper cards are presented, providers should accept these cards for the dates on the cards that indicate when the recipient is eligible. Wisconsin Medicaid encourages providers to keep photocopies of paper cards.
Possession of a Medicaid ID card does not guarantee eligibility. Wisconsin Medicaid providers should always verify a recipient’s eligibility before providing services, both to determine eligibility for the current date and to discover any limitations to the recipient’s coverage. Keep in mind when verifying eligibility with the temporary card or the presumptive eligibility card that eligibility may not be on file right away; the information should be accessible within 7-10 days.
Refer to the Claims Submission section of this handbook for information on eligibility verification and the claims submission process.
Wisconsin Medicaid fee-for-service denies claims submitted for services covered by a recipient’s Medicaid-contracted managed care program.
Refer to the Wisconsin Medicaid Managed Care Guide’s provider section for additional information regarding managed care program noncovered services, emergency services, and hospitalizations.
If Wisconsin Medicaid determines that a recipient is abusing use of the Medicaid ID card or benefits, Wisconsin Medicaid may restrict the recipient’s access to services by assigning the recipient to the Recipient Lock-In Program.
Wisconsin Medicaid only reimburses designated health care providers in lock-in situations; it may reimburse other providers if the services were provided during an emergency or with a referral from the designated health care provider. Refer to the Recipient Rights and Responsibilities section of the All-Provider Handbook for more information about restricted benefit categories and other eligibility issues, such as lock-in status.
Providers are required to notify the Division of Health Care Financing (DHCF) regarding suspected cases of recipient misuse or abuse of Wisconsin Medicaid benefits. Notification may be made by telephoning or by writing to:
Division of Health Care FinancingRefer to the Drug Utilization Review and Pharmaceutical Care section of this handbook for further information on the Recipient Lock-In Program.
As defined in HFS 101.03(75m), Wis. Admin. Code, a hospice is a licensed public agency, a private organization, or a subdivision of either that primarily provides palliative care to persons experiencing the last stages of terminal illness and that provides supportive care for the family and other individuals caring for the terminally ill persons.
Hospice recipients usually receive care from one hospice and one physician. Their prescriptions may be filled at any Medicaid- certified pharmacy.
Hospices are required to pay for medications directly related to the terminal illness, such as narcotics for pain management. Pharmacies should bill these medications directly to the hospice. Medications not directly related to the terminal illness (such as blood pressure medications) should be billed as you would bill other drugs to Wisconsin Medicaid. Refer to the Claims Submission section of this handbook for more information on claims submission processes.
Occasionally an individual with significant medical bills meets all Wisconsin Medicaid requirements except those pertaining to income. These individuals are required to "spenddown" their income to meet Wisconsin Medicaid’s financial requirements.
The certifying agency calculates the individual’s Medicaid spenddown (or deductible) amount, tracks all medical costs the individual incurs, and determines when the medical costs have satisfied the spenddown amount. (A medical service does not have to be paid by the individual to be considered as payment toward satisfying the spenddown amount.)
For more information on spenddown, refer to the Recipient Rights and Responsibilities section of the All-Provider Handbook.
Except as noted under "Copayment Exemptions," recipients are responsible for paying part of the costs involved in obtaining pharmacy services, DMS, and DME. Most legend and over-the-counter (OTC) drugs are subject to a recipient copayment amount. Wisconsin Medicaid automatically deducts applicable copayment amounts from Medicaid payments. Pharmacies should not reduce the billed amount of a claim by the amount of recipient copayments or record any dollar amount in the "Patient Paid" field for real-time claims submission.
The Medicaid copayment amount for legend drugs is $1.00 for each new or refilled prescription, up to a maximum copayment amount of $5.00 per recipient, per provider, per calendar month. The Medicaid copayment amount for OTC drugs (excluding iron supplements for pregnant or lactating women) is $0.50 for each new or refilled prescription.
For OTC drugs, DMS, and DME, there is no limitation on the total amount of copayment a recipient may be required to pay in a calendar month.
For DME and DMS, including enteral nutrition products, Wisconsin Medicaid bases copayments for each procedure code on its maximum allowable fee. The copayment amount for urine and blood glucose test strips remains $0.50.
Copayment exemptions include the following:
All providers who perform services that require recipient copayment must make a reasonable attempt to collect that copayment from the recipient. However, providers may not deny services to a recipient for failing to make a copayment.
|
Copayments: Prescriptions, Disposable Medical Supplies, and Durable Medical Equipment |
|---|
Prescriptions
Legend drugs, no more than $5.00 per month, per recipient, at each pharmacy. |
Disposable Medical Supplies and Durable Medical Equipment
|
Wisconsin Medicaid covers most legend drugs and a limited number of over-the-counter (OTC) drugs.
As defined under HFS 101.03(94), Wis. Admin Code, a legend drug is any drug that requires a prescription under federal code 21 USC 353(b). Legend drugs are covered by Wisconsin Medicaid when:
Some drugs covered by Wisconsin Medicaid may require prior authorization (PA), and others require an appropriate diagnosis code for reimbursement. Refer to Appendices 2 and 3 of this section for lists of Wisconsin Medicaid covered drugs, including PA and diagnosis-restricted drugs. Also refer to the Prior Authorization section of this handbook for more information on PA.
Wisconsin Medicaid uses an open formulary for legend drug products with few restrictions. According to the federal Omnibus Budget Reconciliation Act of 1990 (OBRA ’90), pharmaceutical manufacturers who choose to participate in state Medicaid programs must sign an annual rebate agreement with the federal Health Care Financing Administration (HCFA). Wisconsin Medicaid will cover only the legend drug products of manufacturers who have signed this rebate agreement. Non-participating manufacturers have the option of signing a rebate agreement that is effective the following quarter.
Manufacturer rebates are based on Medicaid claims data showing the quantity of each National Drug Code (NDC) dispensed to Medicaid recipients. Manufacturers may dispute the payment of drug rebates because they believe the utilization data reported to them is inaccurate. To resolve disputes, Wisconsin Medicaid verifies utilization data by having individual providers check the accuracy of claims information they submitted.
Refer to the Pharmacy Data Tables section of this handbook for a list of manufacturers with current rebate agreements and a list of noncovered NDCs and the reasons that manufacturers will not pay rebates on these NDCs.
Wisconsin Medicaid may cover certain legend drugs through the paper PA process even though their manufacturers did not sign rebate agreements. Refer to the Prior Authorization section of this handbook for special instructions to be followed when requesting PA for these drugs.
Wisconsin Medicaid automatically adds an NDC of a new legend drug to the Medicaid drug file if it meets Medicaid guidelines and is produced by a manufacturer participating in the drug rebate program.
Noncovered legend drugs include the following:
Refer to Appendix 6 of this section for a full list of noncovered legend drugs.
Wisconsin Medicaid covers the generic products of specific categories of OTC drugs from manufacturers who have signed rebate agreements with HCFA (as required by OBRA ’90). In addition, Wisconsin Medicaid covers all brands of insulin, ophthalmic lubricants, and contraceptive products. All OTC drugs require legal prescriptions in order to be covered by Wisconsin Medicaid.
As per s. 49.46(2)(b)(6)(i), Wis. Stats., Wisconsin Medicaid covers the following classes of OTC drugs:
Wisconsin Medicaid limits coverage of cough syrups to products that treat only coughs and does not include multiple ingredient cough/cold combination products.*Note:
Refer to Appendix 2 of this section for more information on Medicaid-covered and noncovered OTC drugs. To request an addition of an NDC to the list of covered OTCs, complete Appendix 1 of this section.
Wisconsin Medicaid covers a particular compound drug only when the compound drug prescription:
Wisconsin Medicaid does not cover a compound drug prescription intended for a therapeutic use if the FDA does not approve the therapeutic use of the combination.
Clozapine (Clozaril) is an antipsychotic drug that is indicated for the management of severely ill schizophrenic patients who fail to respond adequately to standard antipsychotic treatment. Food and Drug Administration regulations require that clozapine be made available only when there is a system in place to monitor white blood cell counts.
Wisconsin Medicaid provides reimbursement for clozapine management services if specific requirements are met. Clozapine management is a specialized care management service that may be required to ensure the safety of recipients who are using clozapine. Wisconsin Medicaid may separately reimburse physicians and pharmacies for clozapine management services when all of the conditions listed in Appendix 4 of this section are met.
Home intravenous (IV) injections and total parenteral nutrition (TPN) solution, including lipids, are covered and reimbursed as compounds. Supplies and equipment, such as infusion pumps associated with the IV, may be separately reimbursable. Refer to the Claims Submission section of this handbook for TPN claims submission instructions. Also refer to the Durable Medical Equipment Index and the Disposable Medical Supplies Index for limitations and PA requirements for supplies and equipment.
As a result of the Omnibus Budget Reconciliation Act of 1989 (OBRA `89), Wisconsin Medicaid considers requests for coverage of medically necessary pharmacy services that are not specifically listed as covered services, or that are listed under "Noncovered Services" in the Pharmaceutical Procedures chapter of this section, when all of the following conditions are met:
All requests for HealthCheck "Other Services" require PA, except for those drug categories listed under "Covered Drugs - Over-the-Counter Drugs (HealthCheck "Other Services")" in Appendix 2 of this section. In addition, the drug categories listed in the Wisconsin Medicaid HealthCheck "Other Services" Drug List are covered without PA if the pharmacy documents that the recipient received a comprehensive HealthCheck screening within one year prior to the date on the prescription.
Refer to the Pharmacy Data Tables section of this handbook for the HealthCheck "Other Services" drug list. Also refer to the Prior Authorization section for information on requesting PA for HealthCheck "Other Services."
Wisconsin Medicaid covers medically necessary legend drugs and certain over-the-counter (OTC) drugs identified in the Medicaid Drug File. Only certain licensed health professionals may prescribe legend drugs and OTC drugs according to HFS 107.10(1), Wis. Admin. Code. The professional must be authorized by Wisconsin Statutes or Wisconsin Administrative Code to prescribe legend and/or OTC drugs.
Prescribers may only prescribe items that are within their scope of practice. The following categories of licensed health professionals may prescribe covered legend drugs and OTC drugs:
Except as otherwise provided in federal or state law, either the prescriber must write the prescription or the pharmacist must take the prescription verbally or electronically from the prescriber. The prescription must include the following:
If the pharmacist takes the prescription verbally from the prescriber, the pharmacist must generate a hard copy. Medicaid prescription orders are valid for no more than one year from the date of the prescription, except for controlled substances and prescriber-limited refills which are valid for periods of less than one year.
Wisconsin Medicaid reimburses providers for an innovator drug at an amount greater than the Medicaid maximum allowed cost (MAC) only if the prescriber certifies that the innovator drug is "medically necessary" for that recipient and documents the reason in the recipient’s medical record. An "innovator" drug is the brand-name product of the patented drug on the MAC List.
The phrase "brand medically necessary" must appear in the prescriber’s own handwriting on the face of each new prescription order. It must also appear on each new nursing facility order.
A typed certification, a signature stamp, or a certification handwritten by someone other than the prescriber does not satisfy the requirement. Blanket authorization for an individual recipient, drug, or prescriber is not acceptable documentation.
For claims submission information on "brand medically necessary" drugs, refer to the Claims Submission section of this handbook.
When a prescriber telephones a prescription order to a pharmacy and indicates a medical need for the innovator drug, the pharmacy must inform the prescriber that a handwritten certification is necessary to meet Wisconsin Medicaid’s requirements. Pharmacy providers must have this documentation available before submitting claims to Wisconsin Medicaid. The prescriber may fax the information to the pharmacy.
Providers must retain hard copies of prescription orders for five years from the date of service, according to HFS 105.02(4) and 105.02(7), Wis. Admin. Code, and s. 450.11(2), Wis. Stats. (statutory requirements for the Pharmacy Examining Board). In addition, prescription orders transmitted electronically may be filed and preserved in electronic format, per s. 961.38(2), Wis. Stats. If the pharmacist takes the prescription verbally from the prescriber, the pharmacist must generate a hard copy.
According to HFS 107.10(3)(e), Wis. Admin. Code, providers must dispense the following legend drugs in the quantity prescribed, up to a 100-day supply:
Providers must dispense all other legend drugs in the quantity prescribed, not to exceed a 34-day supply. This policy includes refills.
According to HFS 107.10(3), Wis. Admin. Code, Wisconsin Medicaid limits refills in the following ways:
Phar 7.04, Wis. Admin. Code, specifies that a health care facility may return certain drugs, medicines, or personal hygiene items to the dispensing pharmacy if the medication is in its original container and the pharmacist determines that the contents are unadulterated and uncontaminated. Under federal law, controlled substances may not be returned to the pharmacy.
Pharmacy providers that accept returned Medicaid-covered medications from nursing facilities may assure facility and pharmacy compliance with these regulations by taking the following steps:
Pharmacies are required to refund Medicaid payment to Wisconsin Medicaid for drug prescriptions that cost over $5 and are acceptable for reuse. Pharmacies may not accept returned medications from nursing facilities unless they credit all reusable medications.
A refund must be made on any item returned that is over $5 per prescription. Wisconsin Medicaid allows a pharmacy to retain 20% of the net amount identified as the total cost of reusable units of each drug returned to cover the pharmacy’s administrative costs. Wisconsin Medicaid does not consider dispensing fees part of the total cost and, therefore, the dispensing fees need not be returned.
For claims that were submitted real-time, providers may refund Wisconsin Medicaid by reversing the original claim within 90 days of the submission. A new claim with the adjusted quantity should then be submitted. After 90 days, a paper adjustment must be used to change the quantity on an allowed claim. (Refer to the Claims Submission section of this handbook for the Adjustment Request Form [PDF, 89 KB | Instructions — PDF, 20 KB].)
Pharmacies choosing not to reverse or adjust the original claim must refund Wisconsin Medicaid by check. If this option is chosen, the pharmacy must remit a check to Wisconsin Medicaid for funds representing these reusable drugs no more than once per month or no less than once every three months. Providers remitting a check for returned, reusable medications must maintain a record of the transaction.
Make checks payable to "Department of Health and Family Services." Write "Returned Drugs" on the check. Also, please include your provider number and the dates (MM/DD/YYYY) referenced by the check. Send checks to:
Wisconsin MedicaidUnless otherwise ordered by a physician, the nursing facility must destroy a recipient’s medication not returned to the pharmacy for credit within 72 hours of the following circumstances:
A nursing facility may not retain a recipient’s medication for more than 30 days unless the prescriber orders in writing, every 30 days, that the facility must retain the medication. HFS 132.65(6)(c), Wis. Admin. Code, defines the procedural and record keeping requirements that nursing facilities must follow for recipients’ unused medications.
Pharmacy providers dispensing medications using recipient "compliance aid" packaging (e.g., Pill Minder, blister packaging) must relabel unused quantities when the drug regimen is changed. Providers must not discard unused medications that the recipient still needs. Relabeling and repackaging of medication for reuse by the patient is permitted through Phar 7.04, Wis. Admin. Code.
Under HFS 107.10(4), Wis. Admin. Code, Wisconsin Medicaid does not cover the following pharmacy services and items:
*Note: See the Prior Authorization section of this handbook for exceptions to the rebate agreement requirement.
Based on the claims submission requirements in HFS 106.03(3), Wis. Admin. Code, and the definition of covered services in HFS 107.10, Wis. Admin. Code, the following are examples of unacceptable and, in some cases, fraudulent practices:
Wisconsin Medicaid may suspend or terminate a provider’s Medicaid certification for violations of these or other restrictions that constitute fraud or billing abuses. Refer to HFS 106.06 and 106.08, Wis. Admin. Code, for information on provider sanctions.
The Department of Health and Family Services (dhs) determines maximum reimbursement rates for all covered over-the-counter (OTC) and legend pharmaceutical items. Maximum reimbursement rates may be adjusted to reflect market rates, reimbursement limits, or limits on the availability of federal funding as specified in federal law (42 CFR 447.331).
Providers are required to charge Wisconsin Medicaid their usual and customary charge, meaning the provider’s charge for providing the same service to a private-pay patient.
Some covered legend drugs are reimbursed at either the drug’s Average Wholesale Price (AWP) minus 10% plus a dispensing fee, or the provider’s usual and customary charge, whichever is less. Other legend drugs are reimbursed at either the drug’s price on the Medicaid Maximum Allowed Cost (MAC) List plus a dispensing fee or the provider’s usual and customary charge, whichever is less.
Refer to the Pharmacy Data Tables section of this handbook for the Legend Drug MAC List and the OTC Drug MAC List.
Wisconsin Medicaid reimburses providers for an innovator drug at the same rate that it reimburses for the generic equivalent of the drug if it is on the MAC List, unless the "Brand Medically Necessary" prescription requirements are met. This policy is required by HFS 107.10, Wis. Admin. Code, and by the Omnibus Budget Reconciliation Act of 1990 (OBRA `90) revisions to Title XIX of the Social Security Act.
The estimated acquisition cost for covered OTC drugs is determined by applying a 10% discount to the AWP as listed by First DataBank, except for MAC drugs.
Refer to the Covered Drugs and Services chapter and Appendix 5 of this section for information on Medicaid coverage of OTC drugs. To request an addition of National Drug Codes for unlisted OTCs, complete Appendix 1 of this section.
Wisconsin Medicaid reimburses different dispensing fees depending on the service provided. These fees include the following:
Refer to Appendix 7 of this section for the pharmacy dispensing fee schedule.
A traditional dispensing fee is usually paid once per recipient, per service, per month, per provider, dependent on the physician’s prescription. Refer to the Pharmaceutical Procedures chapter of this section for a list of unacceptable practices.
Wisconsin Medicaid reimburses providers a unit dose dispensing fee when a qualified unit dose dispensing system is used. The drugs may be packaged into unit doses by the manufacturer or by the provider. As per HFS 132.65(7), Wis. Admin. Code, a qualified unit dose dispensing system must:
Multiple dose "blister packs" or "punch cards" are not unit dose packaging and, therefore, are not reimbursable for unit dose dispensing.
The unit dose dispensing fee is limited to one dispensing fee per calendar month, per legend drug, per recipient. Reimbursement is limited to only those pharmaceuticals actually used by the recipient.
Wisconsin Medicaid may pay a repackaging allowance with either a traditional dispensing fee or a unit dose dispensing fee. Wisconsin Medicaid reimburses providers an additional amount per unit (repackaging allowance) in the following two situations:
Situation One: When the provider repackages a drug into unit dose packages. Drugs packaged by a manufacturer do not qualify for the repackaging allowance.
Situation Two: When the provider repackages a drug into a compliance aid system such as "punch cards," "pill minders," or "pill boxes." Wisconsin Medicaid pays the additional amount only for package systems that meet all federal and state requirements for the packaging, labeling, and dispensing of drugs.
Wisconsin Medicaid reimburses providers for the pharmacist’s compounding time. Compounding time is indicated in the level of service field. Refer to the Claims Submission section of this handbook for detailed information on billing for the compound drug dispensing fee.
Providers may receive an enhanced PC dispensing fee if they perform certain additional, documented services. These services must go beyond the basic activities required by federal and state standards for recordkeeping, profiles, prospective Drug Utilization Review, and counseling when dispensing and must result in a positive outcome for both the recipient and for Wisconsin Medicaid. Examples of these services include increasing patient compliance or preventing potential adverse drug reactions.
Reimbursement is based on the following:
Please refer to the Drug Utilization Review and Pharmaceutical Care section of this handbook for more information on PC and the PC dispensing fee.
Wisconsin Medicaid Pharmacy Handbook
July 2001