Preferred Drug List Changes

Wisconsin Medicaid has reviewed the following Preferred Drug List (PDL) classes and made changes to previously reviewed PDL classes. Changes to the PDL are effective for dates of service (DOS) on and after April 2, 2007. These changes apply to Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare. As a reminder, prior authorization (PA) is always required for non-preferred drugs, and all other policies still apply. Providers may begin submitting PA requests for non-preferred drugs in the classes listed below on March 16, 2007. Current, approved PA requests will be honored until their expiration date or until services have been exhausted.

Wisconsin Medicaid and SeniorCare Preferred Drug Lists Available on ePocrates

Wisconsin Medicaid and SeniorCare providers may access the PDL using their personal digital assistants (PDAs) or personal computers through ePocrates. ePocrates’ products provide clinical reference information specifically for health care providers to use at the point of care. Prescribers and pharmacy providers who use PDAs may also subscribe and download the PDL by accessing the ePocrates Web site at www.epocrates.com/.

The tables on the following pages contain the preferred drugs in each class.

ACE Inhibitors/Calcium Channel Blocker Combinations Lotrel Tarka Acne Agents, Topical Akne-mycin Azelex benzoyl peroxide clindamycin erythromycin Retin-A Micro Tazorac tretinoin Agents for Benign Prostatic Hyperplasia (BPH) Avodart doxazosin finasteride Flomax terazosin Uroxatral Analgesics, Narcotics, Long Acting fentanyl transdermal patches Kadian methadone morphine ER oxycodone ER Analgesics, Narcotics, Short Acting acetaminophen/codeine aspirin/codeine butalbital/apap/codeine/caffeine codeine hydrocodone/apap hydrocodone/ibuprofen hydromorphone levorphanol oxycodone oxycodone/apap, aspirin propoxyphene HCL, apap tramadol Angiotensin Receptor Blockers Avapro, Avalide Benicar, HCT Cozaar, Hyzaar Diovan, HCT Micardis, HCT Anticoagulants, Injectables Arixtra Fragmin Lovenox Anticonvulsants carbamazepine Carbatrol Celontin clonazepam Depakote, ER, sprinkle Diastat Equetro ethosuximide Felbatol gabapentin Gabitril Keppra Lamictal Lyrica mephobarbital Peganone phenobarbital phenytoin primidone Topamax Trileptal valproic acid zonisamide Antidepressants, Other bupropion, SR Effexor XR mirtazapine trazodone venlafaxine Antihistamines, Nonsedating loratadine tablet, syrup, loratadine-D Antimigraine, Triptans Amerge Axert Imitrex (oral, nasal, and subcutaneous) Maxalt, MLT Beta Blockers (Alpha/Beta Adrenergic Blocking Agents, Beta-Adrenergic Blocking Agents) acebutolol atenolol betaxolol bisoprolol Coreg labetalol metoprolol nadolol pindolol propranolol, LA sotalol timolol Toprol XL

Bladder Relaxant Preparations (Urinary Tract Antispasmodic/Anti-incontinence Agents) Enablex oxybutynin, ER Oxytrol Sanctura VesiCare Calcium Channel Blocking Agents Cardizem LA diltiazem, ER felodipine ER nicardipine nifedipine, ER Norvasc Sular verapamil, SR Verelan PM Erythropoiesis Stimulating Proteins Aranesp Procrit Growth Hormone Drugs Genotropin† Nutropin AQ† Saizen† Tev-Tropin† †Preferred agents that require clinical PA. Hepatitis C Agents Pegasys Peg-Intron, Redipen ribavirin Hypoglycemics, Meglitinides Starlix Hypoglycemics, Thiazolidinediones Actos Avandamet Avandaryl Avandia Lipotropics, Bile Acid Sequestrants cholestyramine colestipol Lipotropics, Fibric Acids fenofibrate gemfibrozil Tricor Lipotropics, Other Niaspan Vytorin Lipotropics, Statins Advicor Lescol, XL Lipitor lovastatin simvastatin Multiple Sclerosis Agents Avonex Betaseron Copaxone Rebif Otics, Antibiotics Ciprodex Floxin Phosphate Binders and Related Agents Fosrenol Phoslo Renagel Proton Pump Inhibitors Nexium Prevacid (caps, SoluTab, suspension) Sedative Hypnotics Ambien, CR chloral hydrate estazolam flurazepam Lunesta Rozerem temazepam triazolam Ulcerative Colitis Asacol Canasa mesalamine sulfasalazine

Grandfathering

Effective for DOS on and after April 2, 2007, Oxycontin^® will be removed from the list of brand medically necessary drugs. Oxycontin^® will be added as non-preferred drug on the PDL. Providers are required to complete the PA/PDL Exemption Request to obtain PA for Oxycontin^®.

Wisconsin Medicaid will grandfather recipients currently taking Oxycontin^®. Oxycodone ER will remain as a preferred drug as long as the drug is available in the marketplace. Recipients currently taking oxycodone ER may continue filling prescriptions for Oxycontin^® and oxycodone ER for six months without PA. Grandfathering of Oxycontin^® and oxycodone ER for six months is being allowed to ease the transition for recipients who are in need of Oxycontin^®.

New Prior Authorization/Preferred Drug List Form

Effective for DOS on and after April 2, 2007, Exubera will be a non-preferred drug with specific PA criteria. Providers are required to complete the Prior Authorization/Preferred Drug List (PA/PDL) for Exubera, HCF 11294 (03/07), if the drug is dispensed on and after April 2, 2007. Refer to Attachment 1 (PDF, 24 KB) and Attachment 2 (fillable PDF, 308 KB) of this Wisconsin Medicaid and BadgerCare Update for copies of the form and completion instructions.

Prior Authorization Criteria for Prescribing Exubera

Specific PA criteria for prescribing Exubera are:

• The recipient is eighteen years or older.
• The recipient has been a non-smoker for six months or more.
• The recipient does not have a diagnosis of asthma or chronic obstructive pulmonary disease (COPD).
• The recipient has had a pulmonary function test prior to taking Exubera and FEV1 or DLCO results are 70 percent or greater of predicted values. (Note: Pulmonary function tests are recommended prior to initiating Exubera use, after the first six months of therapy, and annually thereafter. If there is a greater than or equal to 20 percent decline from baseline FEV1, Exubera should be discontinued.)
• The recipient has failed to achieve adequate glycemic control with PDL diabetic drugs despite individualized diabetic medication management and a clinician-supervised diet and exercise program.
• The recipient has experienced difficulty with insulin injections or needs to reduce the number of daily insulin injections.

Recipients who have Diabetes Type 1 must use a long-acting insulin and add Exubera as their pre-meal insulin. Exubera must be added as a pre-meal insulin to the recipient’s current diabetic regimen for recipients who have Diabetes Type 2.

Prior Authorization Request Information for Growth Hormone Drugs

When a Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) request is returned because a recipient has not had a stimulated growth hormone test, additional information is required for PA review. If the recipient has a medical condition, such as hypopituitary disease, and a stimulated growth hormone test is not medically indicated, medical records supporting the growth hormone deficiency are required. The medical records should be included with a paper PA request, which includes a completed Prior Authorization Request Form (PA/RF), HCF 10118 (Rev.10/03), PA/PDL for Growth Hormone Drugs, HCF 11092 (03/07), and all supporting documentation.

The prescriber should complete, sign, and submit the PA/PDL for Growth Hormone Drugs and the supporting documentation to the pharmacy where the prescription will be filled. The pharmacy provider is required to complete, sign, and submit the PA/RF, along with the PA/PDL for Growth Hormone Drugs and supporting documentation, to Wisconsin Medicaid. Refer to Attachment 3 (PDF, 25 KB) and Attachment 4 (fillable PDF, 434 KB) for copies of the PA/PDL for Growth Hormone Drugs form and completion instructions.

Reminders

The following are reminders for providers about Wisconsin Medicaid and SeniorCare policies.

Diagnosis-Restricted Drugs

Drugs that are diagnosis restricted continue to be diagnosis restricted even if they are preferred drugs on the PDL. The following are diagnosis-restricted drug classes:

• Erythropoiesis stimulating proteins.
• Hepatitis C agents.
• Multiple sclerosis agents.
• Proton pump inhibitor drugs. (Omeprazole may be approved after a recipient has tried and failed or experienced an adverse reaction to Prevacid^® and Nexium^®.)
• Stimulants and related agents. (Wisconsin Medicaid has added Daytrana™ as a non-preferred stimulant drug on the PA/PDL for Stimulants and Related Agents, HCF 11097 [fillable PDF, 342 KB] [Rev. 06/06].)

Pharmacy providers should continue to submit diagnosis codes on claims for preferred drugs that are also diagnosis restricted. If a drug is diagnosis restricted and non-preferred, pharmacy providers are required to indicate the appropriate diagnosis code on the PA request regardless of whether it is submitted through the STAT-PA system or on paper. Refer to the Pharmacy Data Tables on the Pharmacy page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/ for a list of diagnosis codes for diagnosis-restricted drugs.

Quantity Limits

Quantities of antimigraine triptan drugs 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.

Quantities for Januvia™ are limited to 34 tablets every month.

Refer to the June 2006 Update (2006-53), titled “Quantity Limits Apply to Triptans and Pharmaceutical Care Code Expansion,” for additional information.

Emergency Medication Dispensing

An emergency medication supply may be dispensed in situations where the pharmacy provider or prescriber deem it is medically necessary. Medications dispensed in emergency situations do not require PA.

When drugs are dispensed in an emergency situation, providers are required to submit a Noncompound Drug Claim, HCF 13072 (fillable PDF, 82 KB) (Rev. 06/03), with a Pharmacy Special Handling Request, 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.

Providers may refer to the February 2007 Update (2007-14), titled “Emergency Medication Dispensing,” for additional information.

For More Information

Providers should refer to the PDL page of the Medicaid Web site at dhs.wisconsin.gov/medicaid/pharmacy/pdl/index.htm for the most current PDL. Both preferred and non-preferred drugs are included on the 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 call Provider Services at (800) 947-9627 or (608) 221-9883 for information about Wisconsin Medicaid, BadgerCare, and SeniorCare drug coverage.

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 (PA/PDL) for Exubera Completion Instructions (PDF, 24 KB)
Attachment 2 — Prior Authorization/Preferred Drug List (PA/PDL) for Exubera (fillable PDF, 308 KB) | Word (fillable, 102 KB)
Attachment 3 — Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs Completion Instructions (PDF, 25 KB)
Attachment 4 — Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs (fillable PDF, 434 KB) | Word (fillable, 82 KB)