New Drug Classes

The Preferred Drug List (PDL) will be expanded for Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare on April 1, 2005. Providers should refer to the following tables for preferred drugs in the new therapeutic classes that will be added to the PDL.

Analgesics, Narcotics APAP/Codeine Aspirin/Codeine Butalbital Compound/Codeine Codeine Fentanyl Transdermal Hydrocodone/APAP Hydrocodone/Ibuprofen Hydromorphone Kadian Levorphanol Methadone Morphine Sulfate Oxycodone/APAP Oxycodone/Aspirin Oxycodone IR Pentazocine/APAP Pentazocine/Naloxone Propoxyphene Propoxyphene/APAP Propoxyphene Compound Tramadol Antiemetic Drugs Anzemet Emend Zofran Zofran ODT Antifungals, Topical Ciclopirox Cream Ciclopirox Suspension Clotrimazole Clotrimazole/Betamethasone Econazole Exelderm Ketoconazole Loprox Loprox Shampoo Naftin Nystatin Nystatin/Triamcinolone Antihistamines, Nonsedating Loratadine Benign Prostatic Hyperplasia (BPH) Agents Avodart Doxazosin Flomax Terazosin Uroxatral Bladder Relaxant Preparations (Urinary Tract Antispasmodic/ Anti-Incontinence Agents) Detrol Detrol LA Enablex Oxybutynin Oxytrol Sanctura Bronchodilators, Anticholinergic Atrovent Combivent Ipratropium Nebulizer Spiriva

Bronchodilators, Beta Agonist Albuterol Metaproterenol Serevent Terbutaline Hypoglycemics, Insulins Humalog Humalog Mix 75/25 Humulin Lantus Ophthalmics, Allergic Conjunctivitis Acular Alrex Cromolyn Sodium Elestat Patanol Zaditor Ophthalmics, Antibiotics Bacitracin Bacitracin/Polymixin Ciprofloxacin Solution Erythromycin Gentamicin Ofloxacin Tobramycin Vigamox Zymar Ophthalmics, Glaucoma Agents Alphagan P Azopt Betaxolol Betimol Betoptic S Brimonidine Carteolol Cosopt Dipivefrin Levobunolol Lumigan Metipranolol Pilocarpine Timolol Travatan Trusopt Xalatan Phosphate Binders and Related Agents Phoslo Renagel Ulcerative Colitis Asacol Canasa Dipentum Mesalamine Pentasa Sulfasalazine

On and after April 1, 2005, Caduet will be a preferred drug while Antara and Astelin will be non-preferred drugs.

Providers should note that Wisconsin SeniorCare does not cover over-the-counter drugs. In addition, SeniorCare does not cover drugs that do not have a signed rebate agreement between the manufacturer and Wisconsin SeniorCare for SeniorCare participants in levels 2b and 3. Providers should refer to the SeniorCare drug search tool at dhs.wisconsin.gov/seniorcare/ for a complete list of covered drugs.

Dispensing Provider Requirements for the Preferred Drug List

Dispensing providers should review the Wisconsin Medicaid Preferred Drug List Quick Reference in Attachment 1 of this Wisconsin Medicaid and BadgerCare Update for a complete list of preferred and non-preferred drugs. If medically appropriate for a recipient, prescribers are encouraged to try more than one preferred drug before a non-preferred drug is prescribed. Preferred drugs do not require prior authorization (PA), although these drugs may have other restrictions (e.g., age, diagnosis). If a recipient presents a prescription for a non-preferred drug, the dispensing provider should contact the prescriber to discuss Wisconsin Medicaid preferred drug options.

If a non-preferred drug is medically necessary, the prescriber is required to complete and submit the appropriate Prior Authorization/Preferred Drug List (PA/PDL) form to the dispensing provider and document that the recipient meets one of the clinical criteria requirements for PA approval. Prescribers and dispensing providers are required to retain a completed copy of the appropriate PA/PDL form. Refer to the "Available Prior Authorization/Preferred Drug List Forms" section of this Update for a list of PA/PDL forms that are available for providers’ use.

Nonsedating Antihistamine Drugs

Beginning April 7, 2005, prescribers are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) for Nonsedating Antihistamine Drugs form, HCF 11082 (Dated 03/05), for non-preferred antihistamine drugs.

Clinical criteria for approval of a non-preferred nonsedating antihistamine drug includes the following:

• The trial and failure of, or adverse reaction to, a preferred nonsedating antihistamine drug.
• If the recipient is a child between six months and two years of age.

Refer to Attachment 2 (PDF, 76) and Attachment 3 (fillable PDF, 359 KB) for the Prior Authorization/Preferred Drug List (PA/PDL) for Nonsedating Antihistamine Drugs Completion Instructions, HCF 11082A (Dated 03/05), and a copy of the form.

Current, approved PAs for nonsedating antihistamine drugs will be honored until their expiration date.

Submitting Prior Authorization Requests

Beginning March 17, 2005, prescribers may begin submitting the appropriate PA/PDL form to dispensing providers for the new therapeutic classes of drugs listed in this Update, except for nonsedating antihistamine drugs. Dispensing providers may begin submitting PA requests for non-preferred drugs in the new therapeutic classes listed in this Update, except for nonsedating antihistamine drugs, using the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or the paper PA process beginning March 17, 2005.

The STAT-PA system can be accessed by calling (800) 947-1197 or (608) 221-2096. Paper PA requests can be mailed to the following address:

Wisconsin Medicaid
Prior Authorization
Ste 88
6406 Bridge Rd
Madison WI 53784-0088

Wisconsin Medicaid should not receive PA/PDL forms unless the dispensing provider submits a PA request on paper. Prescribers should submit PA/PDL forms to the dispensing provider where the prescription will be filled.

Clinical Criteria Requirements for Prior Authorization Approval

Providers are reminded that the clinical criteria for PA approval of a non-preferred drug are:

• A treatment failure with a preferred drug(s).
• A condition that prevents the use of a preferred drug(s).
• A clinically significant drug interaction with another medication and a preferred drug(s).
• An intolerable side effect experienced while a recipient is taking a preferred drug(s).

Revised Clinical Criteria Requirements for Proton Pump Inhibitor Drugs

The clinical criteria requirements for Proton Pump Inhibitor (PPI) drugs have been revised. Refer to Attachment 4 (PDF, 81 KB) and Attachment 5 (fillable PDF, 210 KB) for a copy of the revised Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs form, HCF 11078 (Rev. 03/05), and completion instructions.

Emergency Medication Dispensing

An emergency medication supply may be dispensed in situations where the dispensing provider deems it is necessary.

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim form, HCF 13072 (Rev. 06/03 [fillable PDF, 82 KB]), with a Pharmacy Special Handling Request form, HCF 13074 (Rev. 06/03 [fillable PDF, 26 KB]), indicating the nature of the emergency. Mail completed Noncompound Drug Claim forms and Pharmacy Special Handling Request forms to the address indicated on the Pharmacy Special Handling Request form. Medications dispensed in emergency situations do not require PA.

Available Prior Authorization/Preferred Drug List Forms

Prescribers are required to complete the PA/PDL for Nonsedating Antihistamine Drugs or the Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request form, HCF 11075 (Dated 09/04 [fillable PDF, 144 KB]), for non-preferred drugs that do not require step therapy.

The following PA/PDL forms are available for drugs that require step therapy:

• The Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), HCF 11077 (Dated 12/04 [fillable PDF, 114 KB]).
• The PA/PDL for PPI Drugs.

The PA/PDL forms and completion instructions are available on the Forms page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/ or by calling Provider Services at (800) 947-9627 or (608) 221-9883.

For More Information

Changes to the PDL (PDF, 169 KB) and the PDL implementation schedule will be posted to the Pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/. Providers may refer to the September 2004 Update (2004-76), titled "Dispensing Provider Information on the Wisconsin Medicaid Preferred Drug List," for additional information.

Providers can also refer to the ePocrates Web site at www2.epocrates.com/ to access and download the Wisconsin Medicaid PDL to their personal digital assistants (PDAs). Providers may call Provider Services for information about Wisconsin Medicaid, BadgerCare, and SeniorCare coverage of drugs.

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 — Preferred Drug List Quick Reference
Attachment 2 — Prior Authorization / Preferred Drug List (PA/PDL) for Nonsedating Antihistamine Drugs Completion Instructions (PDF, 76 KB)
Attachment 3 — Prior Authorization / Preferred Drug List (PA/PDL) for Nonsedating Antihistamine Drugs (fillable PDF, 359 KB)
Attachment 4 — Prior Authorization / Preferred Drug List (PA.PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions (PDF, 81 KB)
Attachment 5 — Prior Authorization / Preferred Drug List (PA.PDL) for Proton Pump Inhibitor (PPI) Drugs (fillable PDF, 210 KB)