As previously notified in the August 2003 Wisconsin Medicaid and BadgerCare Update (2003-142) titled "Wisconsin Medicaid, BadgerCare, and SeniorCare Changes, for Retail Pharmacies Dispensing Drug Services," pharmacy reimbursement rates will change effective for dates of service on and after July 1, 2004.

For drug reimbursement rates to which the discounted published average wholesale price (AWP) applies, Medicaid and BadgerCare will reimburse at a rate of AWP-13 percent. The same rate change will apply to the Health Insurance Risk Sharing Plan and the Wisconsin Chronic Disease Program.

SeniorCare reimbursement rates will also change. For drug reimbursement rates to which the discounted published AWP applies, SeniorCare will reimburse AWP minus 13 percent plus 5 percent.

Zavesca® is FDA approved only for treatment of Gaucher’s Disease. Therefore its use is limited to that diagnosis. The ICD-9-CM diagnosis code for Gaucher’s Disease is 2727. In addition, Zavesca® is limited to use by individuals ages 19 through 64.

Since Xolair is indicated for adults and adolescents (12 years of age and above) with moderate-to-severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids, its use will be limited to individuals over the age of 12.

Effective for dates of service on and after January 15, 2004, all proton pump inhibitor (PPI) drugs except OTC Prilosec® will require prior authorization (PA) and all PPI drugs remain diagnosis restricted. Currently certain PPI drugs require PA and all PPI drugs are diagnosis restricted.

As recommended by the Wisconsin Medicaid PA Advisory Committee, Medicaid recipients will be required to try OTC Prilosec® even if they are currently taking another PPI drug. If the recipient has failed on omeprazole, PA requests may be granted for one of the brand-name products. In addition, children weighing less than 20 kg, pregnant women and individuals unable to swallow a tablet due to a mechanical swallowing dysfunction secondary to a disease process will be granted PA for one of the other products. As with other OTC medications, Medicaid recipients will continue to need a prescription in order to receive OTC Prilosec®.

SeniorCare does not cover OTC medications. Therefore, SeniorCare recipients will be required to purchase OTC Prilosec®. If a participant has failed on omeprazole, a PA for one of the brand-name products may be granted.

Prior authorization will be available through the STAT-PA system. Pharmacies may begin requesting PA on January 5, 2004, for dates of service on and after January 15, 2004. Attached is a worksheet providers may wish to use when calling the STAT-PA system.

Providers are reminded that when a PA is requested, it may be granted for up to 365 days. When the STAT-PA system asks for a quantity requested, providers should respond "365" if you want a year’s approval. The provider will then be granted a PA number which is used every month for a year.

Providers will not have to submit new or amended PA requests for previously approved PA requests. Subsequent PAs must adhere to the new criteria.

Certain stimulant drugs have been added to the diagnosis-restricted drug list to be effective on and after October 1, 2003. Appendix 7 is a complete listing of drugs requiring diagnosis codes as a part of the drug claim. This list includes the acceptable diagnosis codes for each drug.

Currently proton pump inhibitor (PPI) drugs as well as COX-2 nonsteroidal antiinflammatory drugs (NSAIDs) require prior authorization (PA) but may have several approved PAs for the same drug. Effective October 1, 2003, only one active PA for each drug category will be allowed. Providers are reminded that when a PA is requested, it may be granted for up to 365 days. When the STAT-PA system asks for a quantity requested, you should enter "365." You may then be granted a PA number, which is used every month for a year.

Wisconsin Medicaid covers over-the-counter (OTC) Prilosec. OTC Prilosec does not require PA but remains diagnosis-restricted only.

Under HFS 107.10(4), Wis. Admin. Code, Wisconsin Medicaid does not cover drugs provided for the treatment of impotence. Therefore, Levitra (Vardenafil) is not covered by Wisconsin Medicaid.

Changes to the Data Tables only.

Effective for dates of service on and after April 15, 2003, brand name Antihyperlipidemic drugs (Statins) require prior authorization (PA). PA will be available through the STAT PA system. The criteria for determining whether or not PA will be granted include:

• Any recipient currently on an effective brand name Statin will be granted prior authorization to continue on that Statin drug.

• Any recipient who requires >35 percent LDL reduction, has impaired renal function, or is at high risk for drug interactions will be granted prior authorization to start on the brand name Statin drugs.

• Only recipients new to Statin drugs will be required to try Lovastatin first.

Attachment 1 is an optional worksheet with additional information.

Effective for dates of service on and after May 7, 2003, brand name Proton Pump Inhibitor (PPI) Drugs will require prior authorization (PA). PA will be available through the STAT PA system. All PPI drugs, including generic omeprazole, continue to be diagnosis restricted. PA for brand name PPIs will only be granted when a patient has tried and failed or had an adverse reaction to generic omeprazole. Attachment 2 is an optional worksheet with additional information.

The Drug Addition Request/Correction Form is revised to include the pharmacist’s signature certifying that the price listed on the invoice reflects actual costs net of rebates or any other discounts received from the drug wholesaler or any other entity. Attachment 3 is a copy of the new form for your use. This completed form plus a copy of your invoice must be received to process your request.

Wisconsin Medicaid covers over-the-counter (OTC) Claritin (loratadine) and Alavert OTC Claritin and Alavert are billable through the point-of-sale system. As with all covered OTC products in Medicaid, loratadine requires a prescription. As new generic loratadine products become available, they will be added to the Wisconsin Medicaid covered drug list.

Since SeniorCare does not cover OTCs, SeniorCare does not cover OTC Claritin.

Wisconsin Medicaid will cover over-the-counter (OTC) Claritin (loratadine) as soon as it becomes available. Reimbursement will be at AWP -11.25%. Since SeniorCare does not cover OTCs, OTC Claritin will not be covered by SeniorCare.

Several Explanation of Benefits (EOB) codes were added for SeniorCare

Appendix 8 of the Drug Utilization Review (DUR) and Pharmaceutical Care (PC) chapter of the Pharmacy Handbook understates the allowed frequency of PC services in the following cases:

• Reason code "CS," action code "MO" and all outcome codes indicate a maximum of 1/pt/yr. This should be 2/pt/yr.

• Reason code "TD," action code "MO," outcome code "1E" indicate a maximum of 2/pt/yr. This should be 4/pt/yr.

• In addition, Reason code "RE" Action code "AS" Outcome code "3M" indicate a maximum of 1/pt/day. This should be 2/pt/yr.