Wisconsin Medicaid Pharmacy Data Tables

Drugs Available in a 100-Day Supply

The following list of drugs may be dispensed in quantities of a 100-day supply. An “X” indicates if the brand name or generic form may be dispensed in a quantity of a 100-day supply. Wisconsin Medicaid will accept a claim for reimbursement for any drug marked with an “X” in only the generic column. Drugs may be dispensed in a 100-day supply in only oral solid dosage forms.

Providers will receive the “NS” (insufficient quantity) Drug Utilization Review (DUR) alert on claims for drugs for which a “Y” is listed in the DUR alert column. Drugs for which an “N” is indicated in the DUR alert column will not receive an alert; however, the DUR alert for these drugs will be phased in and providers will receive the alert in the future.

Providers are required to follow existing Medicaid policy requirements (e.g., brand medically necessary, Preferred Drug List) for these drugs.

Effective 11/1/07

Drugs That Will Receive the “NS” DUR Alert if Not Dispensed in Quantities of 100 Days

Brand Name

Generic

DUR Alert
acetazolamide

X

Y
acetohexamide

X

Y
allopurinol

X

Y
amiloride/HCTZ

X

Y
amitriptyline

X

Y
amitriptyline/chlordiazepoxide

X

Y
amitriptyline/perphenazine

X

Y
atenolol

X

Y
atenolol/chlorthalidone

X

Y
benazepril, HCTZ

X

Y
betaxolol

X

Y
bisprolol, HCTZ

X

Y
bumetanide

X

Y
captopril, HCTZ

X

Y
chlorothiazide

X

X

Y
chlorpropamide

X

Y
chlorthalidone

X

Y
chlorthalidone/clonidine

X

Y
cholestyramine

X

Y
cimetidine

X

Y
clofibrate

X

Y
clomipramine

X

Y
clonidine

X

Y
contraceptives

X

X

Y
desipramine

X

Y
diclofenac

X

Y
diflunisal

X

Y
digitalis

X

X

Y
digitoxin

X

X

Y
digoxin

X

X

Y
diltiazem

X

Y
dipyridamole

X

Y
doxazosin

X

Y
doxepin

X

Y
enalapril, HCTZ

X

Y
estradiol

X

Y
estropipate

X

Y
etodolac

X

Y
famotidine

X

Y
felodipine

X

Y
fenofibrate

X

Y
fluoride

X

X

Y
flurbiprofen

X

Y
folic acid

X

Y
fosinopril/HCTZ

X

Y
furosemide

X

Y
gemfibrozil

X

Y
glimepiride

X

Y
glipizide

X

Y
glipizide/metformin

X

Y
glyburide

X

Y
glyburide/metformin

X

Y
hydralazine, HCTZ

X

Y
hydrocholorothiazide

X

X

Y
hydroxyzine

X

Y
ibuprofen

X

Y
imipramine

X

Y
indapamide

X

Y
indomethacin

X

Y
isosorbide

X

Y
ketoprofen

X

Y
labetalol

X

Y
levothyroxine

X

X

Y
liothyronine

X

X

Y
lisinopril, HCTZ

X

Y
lovastatin

X

Y
maprotiline

X

Y
meclofenamate

X

Y
medroxyprogesterone

X

Y
meloxicam

X

Y
metformin

X

Y
metolazone

X

Y
metoprolol, HCTZ

X

Y
mexiletine

X

Y
minoxidil

X

Y
nabumetone

X

Y
nadolol

X

Y
naproxen

X

Y
niacin

X

Y
nicardipine

X

Y
nifedipine

X

Y
nortriptyline

X

Y
omeprazole

X

Y
oxaprozin

X

Y
phenobarbital

X

X

Y
phenytoin

X

X

Y
pindolol

X

Y
Piroxicam

X

Y
prazosin

X

Y
prenatal vitamins

X

X

Y
probenecid

X

Y
propranolol

X

Y
ranitidine

X

Y
simvastatin

X

Y
sotalol

X

Y
spironolactone, HCTZ

X

Y
sulfasalazine

X

Y
sulindac

X

Y
terazosin

X

Y
thyroid extract

X

X

Y
timolol

X

Y
tolazamide

X

Y
tolbutamide

X

Y
tolmetin

X

Y
torsemide

X

Y
trazodone

X

Y
triamterene/HCTZ

X

Y
verapamil

X

Y
warfarin

X

Y

 

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