Notice to Medicaid and BadgerCare Recipients and SeniorCare Participants

Effective September 1, 2004, Wisconsin Medicaid and BadgerCare fee-for-service recipients and all SeniorCare participants will be required to have prior authorization for certain brand name drugs. Prior authorization means your pharmacy has been granted approval by Wisconsin Medicaid or SeniorCare for you to receive the brand name drug. You will need prior authorization for refills and new prescriptions that you receive from your physician of certain brand name drugs. Only one prior authorization is needed for a prescription, not on all refills of each prescription.

This policy only applies to drugs that are available in both brand name and generic versions. Generic drugs work just as well as brand name drugs. In order for you to receive these brand name drugs, your doctor and your pharmacy must receive prior authorization for you to receive the brand name drug. Prior authorization for these brand name drugs will be approved for the following reasons:

• An allergy to the generic drug.
• An adverse reaction to the generic drug, such as intolerable side effects.
• An actual therapeutic failure of the generic drug, such as a condition that would not allow you to take the generic drug.

If your doctor determines that you meet one of these criteria, he/she will:

1. Fill out the Food and Drug Administration MedWatch form.
2. Provide this completed form to the pharmacy where you will fill your prescription by email, fax or mail. You can also take the form with you to the pharmacy.

Your pharmacy will:

1. Send all the documentation to Wisconsin Medicaid for the prior authorization to be processed.
2. Receive notification when the prior authorization process has been completed.
3. Inform you if the prior authorization has been approved or denied.

It may take a few days for the prior authorization process and for a decision to be made on whether the prior authorization has been approved or denied. Once the prior authorization has been approved, you can pick up your prescription. If the prior authorization is denied, you are responsible for payment if the pharmacy informed you before filling your prescription that Wisconsin Medicaid or SeniorCare does not cover the brand name drug.

The list of the brand name drugs that require prior authorization may be found on the Wisconsin Medicaid web site at http://dhs.wisconsin.gov/Medicaid.

The Department of Health and Family Services has made this policy effective only after extensive deliberation that included input and testimony from consumer and medical experts. The Medicaid Prior Authorization Advisory Committee that recommended this policy is comprised of doctors, pharmacists, consumers and mental health advocates.

Questions? Please call Recipient Services at 1-800-362-3002 or SeniorCare Customer Service at 1-800-657-2038.