Preferred Drug List Changes

Effective for dates of service (DOS) and after July 5, 2006, Wisconsin Medicaid will add the atypical antipsychotic drug class to the Preferred Drug List (PDL). Wisconsin Medicaid has reviewed this drug class and will add the following preferred drugs to the PDL.

Atypical Antipsychotics
clozapine
Geodon
Seroquel
Risperdal

Grandfathered Prescriptions

Effective for DOS on and after July 5, 2006, Wisconsin Medicaid will grandfather prescriptions for recipients who are currently taking non-preferred atypical antipsychotic drugs. Recipients currently taking these drugs may remain on the drug indefinitely without prior authorization (PA) with the appropriate prescription. The following are non-preferred drugs that will be grandfathered:

• Abilify.
• Fazaclo.
• Symbyax.
• Zyprexa.

Prior authorization is required only for a recipient who is newly started on an atypical antipsychotic drug. Prior authorization is required for non-preferred drugs and future refills of new non-preferred atypical antipsychotic drugs. If it is medically necessary for a prescriber to switch a recipient to another non-preferred drug in the atypical antipsychotic drug class, PA is required. Beginning June 16, 2006, Wisconsin Medicaid will accept PA requests for non-preferred atypical antipsychotic drugs for recipients who are not grandfathered on these medications.

Note: Prescriber and pharmacy provider responsibilities for the PDL remain unchanged.

Modification to Prior Authorization/Preferred Drug List Forms

The following Prior Authorization/Preferred Drug List (PA/PDL) forms have been revised:

• The Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, HCF 11075 (fillable PDF, 29 KB) (Rev. 06/06).
• The Prior Authorization/Preferred Drug List (PA/PDL) for Stimulants and Related Agents, HCF 11097 (fillable PDF, 37 KB) (Rev. 06/06).

Providers may complete these forms for DOS on and after July 5, 2006.

Wisconsin Medicaid has added the following question to the PA/PDL Exemption Request and the PA/PDL for Stimulants and Related Agents:

Has the recipient taken a non-preferred drug for more than 30 days outside the Wisconsin Medicaid system and had a measurable, therapeutic response?

Prior Authorization/Preferred Drug List Exemption Request

Providers are required to answer the previously indicated question only for drug classes where grandfathering exists. Grandfathering is allowed in the following drug classes:

• Anti-Parkinson agents.
• Antidepressants, other.
• Anticonvulsants.
• Atypical antipsychotics.
• Glaucoma agents.

The PA/PDL Exemption Request form and completion instructions are located in Attachment 1 (PDF, 22 KB) and Attachment 2 (fillable PDF, 29 KB) of this Wisconsin Medicaid and BadgerCare Update for photocopying and may also be downloaded and printed from the Medicaid Web site.

Prior Authorization/Preferred Drug List for Stimulants and Related Agents

In addition to the question that has been added to the PA/PDL for Stimulants and Related Agents form, Wisconsin Medicaid has added Provigil^® approval criteria to this form.

The following approval criteria questions for Provigil^® have been added to the form:

• Does the recipient have a diagnosis of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)?
• Has the recipient tried and failed or had an adverse reaction to two preferred stimulants?
• Does the prescriber have peer-reviewed medical literature to support the proven efficacy of the requested use of the drug for ADD or ADHD?

Prescribers must be aware of the Food and Drug Administration’s review of the use of Provigil^® for ADHD and the identified safety concerns.

If prescribers answer “yes” to all of the previous questions, a PA request for Provigil^® may be approved through the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system.

The PA/PDL for Stimulants and Related Agents form and completion instructions are located in Attachment 3 (PDF, 25 KB) and Attachment 4 (PDF, 37 KB) for photocopying and may also be downloaded and printed from the Medicaid Web site.

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, HCF 13072 (fillable PDF, 82 KB) (Rev. 06/03), with a Pharmacy Special Handling Request form, HCF 13074 (PDF, 17 KB) (Rev. 06/06), indicating the nature of the emergency. Providers should mail the completed Noncompound Drug Claim and Pharmacy Special Handling Request forms as indicated on the Pharmacy Special Handling Request form. Medications dispensed in emergency situations 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 Attachment 5 (PDF, 18 KB) and Attachment 6 (fillable PDF, 23 KB) for photocopying and may also be downloaded and printed from the Medicaid Web site.

For More Information

Providers may refer to the March 2006 Update (2006-32), titled “Spring 2006 Preferred Drug List Review,” and to the PDL page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/pdl/index.htm for the most current PDL.

The PDL may be revised as changes occur. Changes to the PDL are posted on the Pharmacy page of the Medicaid Web site.

Providers may also refer to the Epocrates Web site at www.epocrates.com/ to access and download the Wisconsin Medicaid and SeniorCare PDLs to their personal digital assistants (PDAs).

Providers may call Provider Services at (800) 947-9627 or (608) 221-9883 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 — Prior Authorization/Preferred Drug List Exemption Request Completion Instructions (PDF, 22 KB)
Attachment 2 — Prior Authorization/Preferred Drug List Exemption Request (fillable PDF, 29KB)
Attachment 3 — Prior Authorization/Preferred Drug List for Stimulants and Related Agents Completion Instructions (PDF, 25 KB)
Attachment 4 — Prior Authorization/Preferred Drug List for Stimulants and Related Agents (PDF, 37 KB)
Attachment 5 — Pharmacy Special Handling Request Completion Instructions (PDF, 18 KB)
Attachment 6 — Pharmacy Special Handling Request (PDF, 23 KB)