Wisconsin Medicaid Pharmacy Data Tables

Brand Medically Necessary Drugs That Require Prior Authorization

Page 1 of 3, Effective: 7/1/08

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The following table lists brand medically necessary drugs that require prior authorization (PA). This policy was effective April 1, 2005. Effective for dates of service on and after July 1, 2008, when a brand medically necessary prescription is written, prescribers are required to complete the revised Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) HCF 11083 (dated 7/08). Please submit the PA/BMNA with the prescription to the pharmacy. The PA/BMNA form is found at http://dhs.wisconsin.gov/medicaid4/forms/index.htm.

Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically. All drugs listed in this table are registered or trademarked by the manufacturer.

* This drug does not have a signed rebate agreement on file with the Department of Health and Family Services (DHFS). Wisconsin SeniorCare will not cover a drug that does not have a signed SeniorCare rebate agreement between the manufacturer and the DHFS. Providers should note that drugs without signed rebate agreements for SeniorCare participants in Levels 2b and 3 will not be covered; however, these drugs may be covered for participants in Levels 1 and 2a.

** This drug has a signed rebate agreement with specific manufacturers. Providers may refer to Appendix 1 of the Pharmacy Data Tables section of the Pharmacy Handbook for a list of manufacturers that do not have signed SeniorCare rebate agreements. Providers may also call Provider Services at (800) 947-9627 or (608) 221-9883 to obtain a list of manufacturers with signed rebate agreements, or they can refer to the SeniorCare section of the Pharmacy Handbook for more information on drug rebate agreements.

*** Refer to the "Prior Authorization for Brand Name Clozaril® " section of the August 2004 Wisconsin Medicaid and BadgerCare Update (2004-62) titled "Pharmacy Information on Prior Authorization Requirements for Brand Medically Necessary Drugs."

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