new preferred drug list information for dispensing providers · for proton pump inhibitor drugs the...

Department of Health and Family Services

March 2005 ! No. 2005-17

To:

Blood Banks

DispensingPhysicians

Federally QualifiedHealth Centers

Pharmacies

HMOs and OtherManaged CarePrograms

New Preferred Drug List Information forDispensing ProvidersThe Preferred Drug List will be expanded for Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare on April 1, 2005.

New Drug ClassesThe Preferred Drug List (PDL) will be expanded for Wisconsin Medicaid and BadgerCare fee-for-service and Wisconsin SeniorCare on April 1, 2005. Providers should refer to the following tables forpreferred drugs in the new therapeutic classes that will be added to the PDL.

Analgesics, NarcoticsAPAP/CodeineAspirin/CodeineButalbital Compound/CodeineCodeineFentanyl TransdermalHydrocodone/APAPHydrocodone/IbuprofenHydromorphoneKadianLevorphanolMethadoneMorphine SulfateOxycodone/APAPOxycodone/AspirinOxycodone IRPentazocine/APAPPentazocine/NaloxonePropoxyphenePropoxyphene/APAPPropoxyphene CompoundTramadol

Antiemetic DrugsAnzemetEmendZofranZofran ODT

Antifungals, TopicalCiclopirox CreamCiclopirox SuspensionClotrimazoleClotrimazole/BetamethasoneEconazoleExeldermKetoconazoleLoproxLoprox ShampooNaftinNystatinNystatin/Triamcinolone

Antihistamines, NonsedatingLoratadine

Benign Prostatic Hyperplasia(BPH) AgentsAvodartDoxazosinFlomaxTerazosinUroxatral

Wisconsin Medicaid and BadgerCare Service-Specific Information ! March 2005 ! No. 2005-172

Bladder Relaxant Preparations(Urinary Tract Antispasmodic/Anti-Incontinence Agents)DetrolDetrol LAEnablexOxybutyninOxytrolSanctura

Bronchodilators, AnticholinergicAtroventCombiventIpratropium NebulizerSpiriva

Bronchodilators, Beta AgonistAlbuterolMetaproterenolSereventTerbutaline

Hypoglycemics, InsulinsHumalogHumalog Mix 75/25HumulinLantus

Ophthalmics, AllergicConjunctivitisAcularAlrexCromolyn SodiumElestatPatanolZaditor

Ophthalmics, AntibioticsBacitracinBacitracin/PolymixinCiprofloxacin SolutionErythromycinGentamicinOfloxacinTobramycinVigamoxZymar

Ophthalmics, Glaucoma AgentsAlphagan PAzoptBetaxololBetimolBetoptic SBrimonidineCarteololCosoptDipivefrinLevobunololLumiganMetipranololPilocarpineTimololTravatanTrusoptXalatan

Phosphate Binders and RelatedAgentsPhosloRenagel

Ulcerative ColitisAsacolCanasaDipentumMesalaminePentasaSulfasalazine

On and after April 1, 2005, Caduet will be apreferred drug while Antara and Astelin will benon-preferred drugs.

Providers should note that WisconsinSeniorCare does not cover over-the-counterdrugs. In addition, SeniorCare does not coverdrugs that do not have a signed rebateagreement between the manufacturer andWisconsin SeniorCare for SeniorCareparticipants in levels 2b and 3. Providers shouldrefer to the SeniorCare drug search tool atdhfs.wisconsin.gov/seniorcare/ for acomplete list of covered drugs.

Dispensing Provider Requirements forthe Preferred Drug ListDispensing providers should review theWisconsin Medicaid Preferred Drug List QuickReference in Attachment 1 of this Wisconsin

P roviders should note that

WisconsinSeniorCare doesnot cover over-the-counter drugs.

Wisconsin Medicaid and BadgerCare Service-Specific Information ! March 2005 ! No. 2005-17 3

Medicaid and BadgerCare Update for acomplete list of preferred and non-preferreddrugs. If medically appropriate for a recipient,prescribers are encouraged to try more thanone preferred drug before a non-preferred drugis prescribed. Preferred drugs do not requireprior authorization (PA), although these drugsmay have other restrictions (e.g., age,diagnosis). If a recipient presents a prescriptionfor a non-preferred drug, the dispensingprovider should contact the prescriber todiscuss Wisconsin Medicaid preferred drugoptions.

If a non-preferred drug is medically necessary,the prescriber is required to complete andsubmit the appropriate Prior Authorization/Preferred Drug List (PA/PDL) form to thedispensing provider and document that therecipient meets one of the clinical criteriarequirements for PA approval. Prescribers anddispensing providers are required to retain acompleted copy of the appropriate PA/PDLform. Refer to the �Available PriorAuthorization/Preferred Drug List Forms�section of this Update for a list of PA/PDLforms that are available for providers� use.

Nonsedating Antihistamine DrugsBeginning April 7, 2005, prescribers arerequired to complete the Prior Authorization/Preferred Drug List (PA/PDL) forNonsedating Antihistamine Drugs form, HCF11082 (Dated 03/05), for non-preferredantihistamine drugs.

Clinical criteria for approval of a non-preferrednonsedating antihistamine drug includes thefollowing:� The trial and failure of, or adverse reaction

to, a preferred nonsedating antihistaminedrug.

� If the recipient is a child between sixmonths and two years of age.

Refer to Attachments 2 and 3 for the PriorAuthorization/Preferred Drug List (PA/PDL)for Nonsedating Antihistamine DrugsCompletion Instructions, HCF 11082A(Dated 03/05), and a copy of the form.

Current, approved PAs for nonsedatingantihistamine drugs will be honored until theirexpiration date.

Submitting Prior Authorization RequestsBeginning March 17, 2005, prescribers maybegin submitting the appropriate PA/PDL formto dispensing providers for the new therapeuticclasses of drugs listed in this Update, exceptfor nonsedating antihistamine drugs. Dispensingproviders may begin submitting PA requests fornon-preferred drugs in the new therapeuticclasses listed in this Update, except fornonsedating antihistamine drugs, using theSpecialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or thepaper PA process beginning March 17, 2005.

The STAT-PA system can be accessed bycalling (800) 947-1197 or (608) 221-2096.Paper PA requests can be mailed to thefollowing address:

Wisconsin MedicaidPrior AuthorizationSte 886406 Bridge RdMadison WI 53784-0088

Wisconsin Medicaid should not receivePA/PDL forms unless the dispensing providersubmits a PA request on paper. Prescribersshould submit PA/PDL forms to the dispensingprovider where the prescription will be filled.

P rescribers anddispensingproviders arerequired toretain acompleted copyof theappropriatePA/PDL form.


Clinical Criteria Requirements for PriorAuthorization ApprovalProviders are reminded that the clinical criteriafor PA approval of a non-preferred drug are:� A treatment failure with a preferred

drug(s).� A condition that prevents the use of a

preferred drug(s).� A clinically significant drug interaction with

another medication and a preferreddrug(s).

� An intolerable side effect experiencedwhile a recipient is taking a preferreddrug(s).

Revised Clinical Criteria Requirementsfor Proton Pump Inhibitor DrugsThe clinical criteria requirements for ProtonPump Inhibitor (PPI) drugs have been revised.Refer to Attachments 4 and 5 for a copy of therevised Prior Authorization/Preferred Drug List(PA/PDL) for Proton Pump Inhibitor (PPI)Drugs form, HCF 11078 (Rev. 03/05), andcompletion instructions.

Emergency Medication DispensingAn emergency medication supply may bedispensed in situations where the dispensingprovider deems it is necessary.

When drugs are dispensed in an emergencysituation, providers are required to submit aNoncompound Drug Claim form, HCF 13072(Rev. 06/03), with a Pharmacy SpecialHandling Request form, HCF 13074(Rev. 06/03), indicating the nature of theemergency. Mail completed NoncompoundDrug Claim forms and Pharmacy SpecialHandling Request forms to the addressindicated on the Pharmacy Special HandlingRequest form. Medications dispensed inemergency situations do not require PA.

Available Prior Authorization/PreferredDrug List FormsPrescribers are required to complete thePA/PDL for Nonsedating Antihistamine Drugsor the Prior Authorization/Preferred Drug List(PA/PDL) Exemption Request form, HCF11075 (Dated 09/04), for non-preferred drugsthat do not require step therapy.

The following PA/PDL forms are available fordrugs that require step therapy:� The Prior Authorization/Preferred Drug

List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), HCF11077 (Dated 12/04).

� The PA/PDL for PPI Drugs.

The PA/PDL forms and completion instructionsare available on the Forms page of theMedicaid Web site atdhfs.wisconsin.gov/medicaid/ or by callingProvider Services at (800) 947-9627 or(608) 221-9883.

For More InformationChanges to the PDL and the PDLimplementation schedule will be posted to thePharmacy page of the Medicaid Web site atdhfs.wisconsin.gov/medicaid/pharmacy/.Providers may refer to the September 2004Update (2004-76), titled �Dispensing ProviderInformation on the Wisconsin MedicaidPreferred Drug List,� for additional information.

Providers can also refer to the ePocrates Website at www.epocrates2.com/ to access anddownload the Wisconsin Medicaid PDL to theirpersonal digital assistants (PDAs). Providersmay call Provider Services for informationabout Wisconsin Medicaid, BadgerCare, andSeniorCare coverage of drugs.

M edications dispensed in

emergencysituations do notrequire PA.


Information Regarding MedicaidHMOsThis Update contains Medicaid fee-for-servicepolicy and applies to providers of services torecipients on fee-for-service Medicaid only. ForMedicaid HMO or managed care policy,contact the appropriate managed careorganization. Wisconsin Medicaid HMOs arerequired to provide at least the same benefits asthose provided under fee-for-servicearrangements.

The Wisconsin Medicaid and BadgerCareUpdate is the first source of program policy andbilling information for providers.

Although the Update refers to Medicaidrecipients, all information applies to BadgerCarerecipients and SeniorCare participants also.

Wisconsin Medicaid, BadgerCare, and SeniorCareare administered by the Division of Health CareFinancing, Wisconsin Department of Health andFamily Services, P.O. Box 309, Madison, WI53701-0309.

For questions, call Provider Services at(800) 947-9627 or (608) 221-9883 or visit our Website at dhfs.wisconsin.gov/medicaid/.

PHC 1250


ATTACHMENT 1Preferred Drug List Quick Reference

The following table includes the current and new therapeutic classes, effective April 1, 2005, on the Wisconsin MedicaidPreferred Drug List (PDL). Preferred drugs are indicated with a �P.� Non-preferred drugs require prior authorization (PA)and are indicated with �PA.�

Analgesics, NarcoticsAPAP/Codeine PAspirin/Codeine PButalbital Compound/Codeine PCodeine PFentanyl Transdermal PHydrocodone/APAP PHydrocodone/Ibuprofen PHydromorphone PKadian PLevorphanol PMethadone PMorphine Sulfate POxycodone/APAP POxycodone/Aspirin POxycodone IR PPentazocine/APAP PPentazocine/Naloxone PPropoxyphene PPropoxyphene/APAP PPropoxyphene Compound PTramadol PActiq PAAvinza PADarvon-N PAMeperidine PAOxycodone ER PAOxycontin PAPalladone PAPanlor DC/SS PASynalgos-DC PAUltracet PA

Angiotensin ConvertingEnzyme (ACE) Inhibitor andCalcium Channel Blocker DrugsLexxel PLotrel PTarka P

Angiotensin Receptor BlockersCozaar PDiovan PHyzaar PMicardis PAtacand PAAvalide PAAvapro PABenicar PATeveten PA

Antiemetic DrugsAnzemet PEmend PZofran PZofran ODT PKytril PA

Antifungals, OralClotrimazole PFluconazole PGrifulvin V Suspension PGriseofulvin PItraconazole PKetoconazole PLamisil PNystatin PAncobon PAMycostatin PAVfend PA

Antifungals, TopicalCiclopirox Cream PCiclopirox Suspension PClotrimazole PClotrimazole/Betamethasone PEconazole PExelderm PKetoconazole PLoprox PLoprox Shampoo PNaftin PNystatin PNystatin/Triamcinolone PErtaczo PAMentax PAOxistat PAPenlac PA

Antihistamines, NonsedatingLoratadine PAllegra PAAllegra-D PAClarinex PAClarinex Syrup PAZyrtec PAZyrtec Chewable PAZyrtec-D PAZyrtec Syrup PA

Antimigraine, TriptansAmerge PAxert PImitrex PFrova PAMaxalt PARelpax PAZomig PA

Antivirals, InfluenzaAmantadine PRimantadine HCl PTamiflu PRelenza PA

Antivirals, OtherAcyclovir PValcyte PValtrex PFamvir PAGanciclovir (Cytovene) PA

Benign Prostatic Hyperplasia(BPH) AgentsAvodart PDoxazosin PFlomax PTerazosin PUroxatral PProscar PA

Beta Blockers (Alpha/BetaAdrenergic Blocking Agents,Beta-Adrenergic BlockingAgents)Acebutolol PAtenolol PBetaxolol PBisoprolol PCoreg PLabetalol PMetoprolol PNadolol PPindolol PPropranolol PSotalol PTimolol PToprol XL PCartrol PAInderal LA PAInnopran XL PALevatol PA


Bladder Relaxant Preparations(Urinary Tract Antispasmodic/Anti-Incontinence Agents)Detrol PDetrol LA PEnablex POxybutynin POxytrol PSanctura PDitropan XL PAVesicare PA

Bone Resorption, Suppression,and Related Agents

Actonel PFosamax PMiacalcin PDidronel PAEvista PA

Bronchodilators, AnticholinergicAtrovent PCombivent PIpratropium Nebulizer PSpiriva PDuoneb PA

Bronchodilators, Beta AgonistAlbuterol PMetaproterenol PSerevent PTerbutaline PAccuneb PAAlupent Inhaler PAForadil PAMaxair Autohaler PAVospire ER PAXopenex PA

Calcium Channel BlockingAgentsCardizem LA PDiltiazem PDynacirc PFelodipine ER PNicardipine PNifedipine PNorvasc PSular PVerapamil PCardene SR PACovera-HS PANimotop PAVerelan PM PA

Cephalosporins and RelatedAgents (Cephalosporins,Second and Third Generation,Penicillins)Amox TR-ClavulanatePotassium P

Augmentin XR PCefaclor PCefadroxil PCefpodoxime PCefuroxime PCephalexin POmnicef PSpectracef PCedax PACefzil PALorabid PAPanixine PARaniclor PASuprax PA

FluoroquinolonesAvelox PCiprofloxacin PCipro XR PLevaquin PNoroxin PTequin PFactive PAMaxaquin PAOfloxacin (Floxin) PA

Glucocorticoids, InhaledAdvair Diskus PAerobid PAzmacort PFlovent PPulmicort Respules PQvar PPulmicort Turbuhaler PA

Hypoglycemics, InsulinsHumalog PHumalog Mix 75/25 PHumulin PLantus PNovolin PANovolog PANovolog Mix 70/30 PA

Hypoglycemics,ThiazolidinedionesActos PAvandia P

Intranasal Rhinitis AgentsFlonase PFlunisolide PIpratropium PNasarel PNasonex PAstelin PABeconase AQ PANasacort AQ PARhinocort Aqua PA

Leukotriene ModifiersAccolate PSingulair P

Lipotropics, OtherAdvicor PCholestyramine PColestid PGemfibrozil PLofibra PNiacin PNiaspan PZetia PAntara PATricor PAWelchol PA

Lipotropics, StatinsAltoprev PCaduet PCrestor PLescol PLipitor PLovastatin PVytorin PZocor PPravachol PAPravigard PAC PA

Macrolides and KetolidesErythromycin PZithromax PBiaxin PAKetek PA


Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)(This class requires step therapy.)Diclofenac PEtodolac PFenoprofen PFlurbiprofen PIbuprofen PIndomethacin PKetoprofen PKetorolac PMeclofenamate PNabumetone PNaproxen POxaprozin PPiroxicam PSulindac PTolmetin PArthrotec PABextra PACelebrex PAMobic PAPonstel PAPrevacid NapraPAC PA

Ophthalmics, AllergicConjunctivitisAcular PAlrex PCromolyn Sodium PElestat PPatanol PZaditor PAlamast PAAlocril PAAlomide PAEmadine PAOptivar PA

Ophthalmics, AntibioticsBacitracin PBacitracin/Polymixin PCiprofloxacin Solution PErythromycin PGentamicin POfloxacin PTobramycin PVigamox PZymar PCiloxan Ointment PAQuixin PA

Ophthalmics, Glaucoma AgentsAlphagan P PAzopt PBetaxolol PBetimol PBetoptic S PBrimonidine PCarteolol PCosopt PDipivefrin PLevobunolol PLumigan PMetipranolol PPilocarpine PTimolol PTravatan PTrusopt PXalatan PIstalol PA

Otics, Antibiotics (EarPreparations; OticPreparations, Anti-Inflammatory Antibiotics)Ciprodex PColy-mycin S PFloxin PNeomycin/Polymixin/Hydrocortisone P

Cipro HC PACortisporin-TC PA

Phosphate Binders and RelatedAgentsPhoslo PRenagel PFosrenol PAMagnebind 400 RX PA

Proton Pump Inhibitor (PPI)Drugs (This class requires steptherapy.)Prilosec OTC PAciphex PANexium PAOmeprazole (Prilosec) PAPrevacid PAProtonix PAZegerid PA

Topical Immunomodulators(Dermatitis)Elidel PProtopic P

Ulcerative ColitisAsacol PCanasa PDipentum PMesalamine PPentasa PSulfasalazine PColazal PA

Note: Wisconsin SeniorCare does notcover over-the-counter drugs. Inaddition, SeniorCare does not coverdrugs that do not have a signed rebateagreement between the manufacturerand Wisconsin SeniorCare forSeniorCare participants in levels 2b and3. Providers should refer to theSeniorCare drug search tool atdhfs.wisconsin.gov/seniorcare/ for acomplete list of covered drugs.


ATTACHMENT 2Prior Authorization/Preferred Drug List (PA/PDL) for

Nonsedating Antihistamine Drugs Completion Instructions

(A copy of the �Prior Authorization/Preferred Drug List [PA/PDL] for NonsedatingAntihistamine Drugs Completion Instructions� is located on the following pages.)


(This page was intentionally left blank.)

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 11082A (03/05)

WISCONSIN MEDICAIDPRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL)

FOR NONSEDATING ANTIHISTAMINE DRUGS COMPLETION INSTRUCTIONS

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligiblerecipients. Although these instructions refer to Medicaid recipients, all information applies to BadgerCare recipients and SeniorCareparticipants.

Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims forMedicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name,address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code).

Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is usedfor purposes directly related to Medicaid administration such as determining eligibility of the applicant, processing prior authorization(PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result indenial of PA or Medicaid payment for the services.

The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form and isformatted exactly like this form. Refer to the Pharmacy Handbook for service restrictions and additional documentation requirements.Provide enough information for Wisconsin Medicaid, BadgerCare, or SeniorCare to make a reasonable judgment about the case.

Prescribers are required to complete and sign the Prior Authorization/Preferred Drug List (PA/PDL) for Nonsedating AntihistamineDrugs form, HCF 11082. Dispensing providers (e.g., pharmacies, dispensing physicians, federally qualified health centers, blood banks)are required to use the PA/PDL for Nonsedating Antihistamine Drugs to request PA using the Specialized Transmission ApprovalTechnology-Prior Authorization (STAT-PA) system or to submit a paper PA request. Prescribers and dispensing providers are requiredto retain a completed copy of the form.

Providers may submit PA/PDL requests in one of the following ways:

1) For STAT-PA requests, dispensing providers should call (800) 947-1197 or (608) 221-2096.

2) For paper PA requests, dispensing providers may fax to Wisconsin Medicaid at (608) 221-8616.

3) For paper PA requests by mail, dispensing providers should submit a Prior Authorization Request Form (PA/RF) and a PA/PDL forNonsedating Antihistamine Drugs to the following address:


The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billingclaim(s).

SECTION I � RECIPIENT INFORMATION

Element 1 � Name � RecipientEnter the recipient�s last name, followed by his or her first name and middle initial. Use the Eligibility Verification System (EVS) toobtain the correct spelling of the recipient�s name. If the name or spelling of the name on the Medicaid identification card and the EVSdo not match, use the spelling from the EVS.

Element 2 � Date of Birth � RecipientEnter the recipient�s date of birth in MM/DD/YYYY format (e.g., September 8, 1996, would be 09/08/1996).

Element 3 � Recipient Medicaid Identification NumberEnter the recipient�s 10-digit Medicaid identification number. Do not enter any other numbers or letters.

SECTION II � PRESCRIPTION INFORMATION

Element 4 � Drug NameEnter the drug name.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NONSEDATING ANTIHISTAMINE DRUGS Page 2 of 3COMPLETION INSTRUCTIONSHCF 11082A (03/05)

Element 5 � StrengthEnter the strength of the drug listed in Element 4.

Element 6 � Date Prescription WrittenEnter the date the prescription was written.

Element 7 � Directions for UseEnter the directions for use of the drug.

Element 8 � Diagnosis � Primary Code and / or DescriptionEnter the appropriate International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis code and/ordescription most relevant to the drug requested. The ICD-9-CM diagnosis code must match the ICD-9-CM description.

Element 9 � Name � PrescriberEnter the name of the prescriber.

Element 10 � Drug Enforcement Agency NumberEnter the nine-character Drug Enforcement Agency (DEA) number of the prescribing provider. This number must be two alphacharacters followed by seven numeric characters. If the DEA number cannot be obtained or the prescriber does not have a DEAnumber, use one of the following default codes:

XX5555555 � Prescriber�s DEA number cannot be obtained.XX9999991 � Prescriber does not have a DEA number.

These default codes must not be used for prescriptions for controlled substances.

Element 11 � Address � PrescriberEnter the complete address of the prescriber�s practice location, including the street, city, state, and zip code.

Element 12 � Telephone Number � PrescriberEnter the telephone number, including the area code, of the office, clinic, facility, or place of business of the prescriber.

SECTION III � CLINICAL INFORMATIONInclude diagnostic and clinical information explaining the need for the product requested. In Elements 13 and 14, check �yes� to allthat apply.

Element 13Check the appropriate box to indicate if the recipient has experienced a treatment failure or had an adverse reaction to loratadine orloratadine products with pseudoephedrine. If �yes� is checked, indicate the failed drug(s) or adverse reaction that is attributed toloratadine or loratadine products with pseudoephedrine and the dates the drug(s) was taken.

Element 14Check the appropriate box to indicate if the recipient is a child between six months and two years of age.

Element 15 � Signature � PrescriberThe prescriber is required to complete and sign this form.

Element 16 � Date SignedEnter the month, day, and year the PA/PDL for Nonsedating Antihistamine Drugs was signed (in MM/DD/YYYY format).

SECTION IV � FOR DISPENSING PROVIDERS USING STAT-PA

Element 17 � National Drug CodeEnter the appropriate 11-digit National Drug Code (NDC) code for each drug.

Element 18 � Days� Supply RequestedEnter the requested days� supply.

Element 19 � Wisconsin Medicaid Provider Identification NumberEnter the provider�s eight-digit Wisconsin Medicaid provider identification number.

Element 20 � Date of ServiceEnter the requested first date of service (DOS) for the drug. For STAT-PA requests, the DOS may be up to 31 days in the future or upto fourteen days in the past.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NONSEDATING ANTIHISTAMINE DRUGS Page 3 of 3COMPLETION INSTRUCTIONSHCF 11082A (03/05)

Element 21 � Place of ServiceEnter the appropriate National Council for Prescription Drug Programs (NCPDP) patient location code designating where therequested item would be dispensed.

Code Description00 Not specified01 Home04 Long Term/Extended care07 Skilled Care Facility10 Outpatient

Element 22 � Assigned Prior Authorization NumberRecord the seven-digit PA number assigned by the STAT-PA system.

Element 23 � Grant DateRecord the date the PA was approved by the STAT-PA system.

Element 24 � Expiration DateRecord the date the PA expires as assigned by the STAT-PA system.

Element 25 � Number of Days ApprovedRecord the number of days for which the STAT-PA request was approved by the STAT-PA system.

SECTION V � ADDITIONAL INFORMATION

Element 26Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for theproduct requested may also be included here.



Nonsedating Antihistamine Drugs

(A copy of the �Prior Authorization/Preferred Drug List [PA/PDL] for NonsedatingAntihistamine Drugs� is located on the following pages.)

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 11082 (03/05)


FOR NONSEDATING ANTIHISTAMINE DRUGS

INSTRUCTIONS: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) forNonsedating Antihistamine Drugs Completion Instructions (HCF 11082A).

Dispensing providers are required to have a completed PA/PDL for Nonsedating Antihistamine Drugs form signed by the prescriberbefore calling the Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or submitting a paper PArequest.


1. Name � Recipient (Last, First, Middle Initial) 2. Date of Birth � Recipient

3. Recipient Medicaid Identification Number


4. Drug Name 5. Strength

6. Date Prescription Written 7. Directions for Use

8. Diagnosis � Primary Code and / or Description

9. Name � Prescriber 10. Drug Enforcement Agency Number

11. Address � Prescriber (Street, City, State, Zip Code)

12. Telephone Number � Prescriber

SECTION III � CLINICAL INFORMATION

13. Has the recipient tried and failed loratadine (including loratadine products with or without pseudoephedrine)

or had an adverse drug reaction? " Yes " No If yes, what adverse reaction has the recipient experienced that can be directly attributed to loratadine?

14. Is the recipient between six months and two years of age? " Yes " No

15. SIGNATURE � Prescriber 16. Date Signed

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR NONSEDATING ANTIHISTAMINE DRUGS Page 2 of 2HCF 11082 (03/05)


17. National Drug Code (11 digits) 18. Days� Supply Requested*

19. Wisconsin Medicaid Provider Identification Number (Eight digits)

20. Date of Service (MM/DD/YYYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up tofourteen days in the past.)

21. Place of Service (Patient Location) (Use patient location code �00� [Not specified], �01� [Home], �04� [Long Term / Extended Care],�07� [Skilled Care Facility], or �10� [Outpatient])

22. Assigned PA Number (Seven digits)

23. Grant Date 24. Expiration Date 25. Number of Days Approved


26. Include any additional information in the space below. For example, providers may include that this PA request is being submitted for a recipient who was granted retroactive eligibility by Wisconsin Medicaid, BadgerCare, or SeniorCare.

* Days� supply requested equals the total number of days requested for the PA. For example, for a one-year PA, providers should enter�365.�



Proton Pump Inhibitor (PPI) Drugs CompletionInstructions

(A copy of the �Prior Authorization/Preferred Drug List [PA/PDL] for Proton PumpInhibitor [PPI] Drugs Completion Instructions� is located on the following pages.)


(This page was intentionally left blank.)

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 11078A (Rev. 03/05)


FOR PROTON PUMP INHIBITOR (PPI) DRUGSCOMPLETION INSTRUCTIONS

Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligiblerecipients. Although these instructions refer to Medicaid recipients, all information applies to BadgerCare recipients and SeniorCareparticipants.

Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims forMedicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name,address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code).

Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is usedfor purposes directly related to Medicaid administration such as determining eligibility of the applicant, processing prior authorization(PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result indenial of PA or Medicaid payment for the services.

The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form and isformatted exactly like this form. Refer to the Pharmacy Handbook for service restrictions and additional documentation requirements.Provide enough information for Wisconsin Medicaid, BadgerCare, or SeniorCare to make a reasonable judgment about the case.

Prescribers are required to complete and sign the Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI)Drugs form, HCF 11078. Dispensing providers (e.g., pharmacies, dispensing physicians, federally qualified health centers, blood banks)are required to use the PA/PDL for PPI Drugs to request PA using the Specialized Transmission Approval Technology-PriorAuthorization (STAT-PA) system or to submit a paper PA request. Prescribers and dispensing providers are required to retain acompleted copy of the form.

Providers may submit PA/PDL requests in one of the following ways:

1) For STAT-PA requests, dispensing providers should call (800) 947-1197 or (608) 221-2096.

2) For paper PA requests, dispensing providers may fax to Wisconsin Medicaid at (608) 221-8616.

3) For paper PA requests by mail, dispensing providers should submit a Prior Authorization Request Form (PA/RF) and a PA/PDL forPPI Drugs to the following address:


The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billingclaim(s).


Element 1 � Name � RecipientEnter the recipient�s last name, followed by his or her first name and middle initial. Use the Eligibility Verification System (EVS) toobtain the correct spelling of the recipient�s name. If the name or spelling of the name on the Medicaid identification card and the EVSdo not match, use the spelling from the EVS.

Element 2 � Date of Birth � RecipientEnter the recipient�s date of birth in MM/DD/YYYY format (e.g., September 8, 1996, would be 09/08/1996).

Element 3 � Recipient Medicaid Identification NumberEnter the recipient�s 10-digit Medicaid identification number. Do not enter any other numbers or letters.


Element 4 � Drug NameEnter the drug name.

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR PROTON PUMP INHIBITOR (PPI) DRUGS Page 2 of 3COMPLETION INSTRUCTIONSHCF 11078A (Rev. 03/05)

Element 5 � StrengthEnter the strength of the drug listed in Element 4.

Element 6 � Date Prescription WrittenEnter the date the prescription was written.

Element 7 � Directions for UseEnter the directions for use of the drug.

Element 8 � Diagnosis � Primary Code and / or DescriptionEnter the appropriate International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) diagnosis code and/ordescription most relevant to the drug or biologic requested. The ICD-9-CM diagnosis code must match the ICD-9-CM description.The diagnosis code for PPIs must be one of the PPI-approved codes.

Element 9 � Name � PrescriberEnter the name of the prescriber.

Element 10 � Drug Enforcement Agency NumberEnter the nine-character Drug Enforcement Agency (DEA) number of the prescribing provider. This number must be two alphacharacters followed by seven numeric characters. If the DEA number cannot be obtained or the prescriber does not have a DEAnumber, use one of the following default codes:

XX5555555 � Prescriber�s DEA number cannot be obtained.XX9999991 � Prescriber does not have a DEA number.

These default codes must not be used for prescriptions for controlled substances.

Element 11 � Address � PrescriberEnter the complete address of the prescriber�s practice location, including the street, city, state, and zip code.

Element 12 � Telephone Number � PrescriberEnter the telephone number, including the area code, of the office, clinic, facility, or place of business of the prescriber.

SECTION IIIA � CLINICAL INFORMATION FOR PROTONIX

Include diagnostic and clinical information explaining the need for the product requested. In Elements 13 through 16, check �yes� toall that apply.

Element 13Check the appropriate box to indicate if the recipient has experienced a treatment failure or had an adverse reaction to PrilosecOTC. If �yes� is checked, indicate the failed drug(s) or adverse reaction that is attributed to Prilosec OTC and the dates the drug(s)was taken.

Element 14Check the box to indicate if the recipient is a pregnant woman.

SECTION IIIB � CLINICAL INFORMATION FOR NON-PREFERRED PPI DRUGS

Element 15Check the appropriate box to indicate if the recipient has experienced a treatment failure or had an adverse reaction with PrilosecOTC and Protonix. If �yes� is checked, indicate the failed drug(s) or adverse reaction that is attributed to Prilosec OTC andProtonix and the dates the drug(s) was taken.

Element 16 Check the box to indicate if the recipient is a child who weighs less than 20 kilograms.

Element 17 � Signature � PrescriberThe prescriber is required to complete and sign this form.

Element 18 � Date SignedEnter the month, day, and year the PA/PDL for PPI Drugs was signed (in MM/DD/YYYY format).

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR PROTON PUMP INHIBITOR (PPI) DRUGS Page 3 of 3COMPLETION INSTRUCTIONSHCF 11078A (Rev. 03/05)


Element 19 � National Drug CodeEnter the appropriate 11-digit National Drug Code (NDC) code for each drug.

Element 20 � Days� Supply RequestedEnter the requested days� supply.

Element 21 � Wisconsin Medicaid Provider Identification NumberEnter the provider�s eight-digit Wisconsin Medicaid provider identification number.

Element 22 � Date of ServiceEnter the requested first date of service (DOS) for the drug. For STAT-PA requests, the DOS may be up to 31 days in the future or upto fourteen days in the past.

Element 23 � Place of ServiceEnter the appropriate National Council for Prescription Drug Programs (NCPDP) patient location code designating where therequested item would be dispensed.

Code Description00 Not specified01 Home04 Long Term/Extended care07 Skilled Care Facility10 Outpatient

Element 24 � Assigned Prior Authorization NumberRecord the seven-digit PA number assigned by the STAT-PA system.

Element 25 � Grant DateRecord the date the PA was approved by the STAT-PA system.

Element 26 � Expiration DateRecord the date the PA expires as assigned by the STAT-PA system.

Element 27 � Number of Days ApprovedRecord the number of days for which the STAT-PA request was approved by the STAT-PA system.


Element 28Indicate any additional information in the space provided. Additional diagnostic and clinical information explaining the need for theproduct requested may also be included here.



Proton Pump Inhibitor (PPI) Drugs

(A copy of the �Prior Authorization/Preferred Drug List [PA/PDL] for Proton PumpInhibitor [PPI] Drugs� is located on the following pages.)

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 11078 (Rev. 03/05)


FOR PROTON PUMP INHIBITOR (PPI) DRUGS

INSTRUCTIONS: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred Drug List (PA/PDL) forProton Pump Inhibitor (PPI) Drugs Completion Instructions (HCF 11078A).

Dispensing providers are required to have a completed PA/PDL for PPI Drugs form signed by the prescriber before calling theSpecialized Transmission Approval Technology-Prior Authorization (STAT-PA) system or submitting a paper PA request.


1. Name � Recipient (Last, First, Middle Initial) 2. Date of Birth � Recipient

3. Recipient Medicaid Identification Number


4. Drug Name 5. Strength

6. Date Prescription Written 7. Directions for Use

8. Diagnosis � Primary Code and / or Description (The diagnosis code must be one of the PPI-approved codes.*)

9. Name � Prescriber 10. Drug Enforcement Agency Number

11. Address � Prescriber (Street, City, State, Zip Code)

12. Telephone Number � Prescriber

SECTION IIIA � CLINICAL INFORMATION FOR PROTONIX

13. Has the recipient tried and failed or had an adverse drug reaction to Prilosec OTC? " Yes " No

If yes, what adverse reaction has the recipient experienced that is attributed to Prilosec OTC?

14. Is the recipient a pregnant woman? " Yes " No

SECTION IIIB � CLINICAL INFORMATION FOR NON-PREFERRED PPI DRUGS

15. Has the recipient tried and failed or had an adverse drug reaction to Prilosec OTC and " Yes " No

Protonix? If yes, what adverse reactions did the recipient experience that is attributed to Prilosec OTC and Protonix?

16. Is the recipient a child who weighs less than 20 kilograms? " Yes " No

17. SIGNATURE � Prescriber 18. Date Signed

Continued

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR PROTON PUMP INHIBITOR (PPI) DRUGS Page 2 of 2HCF 11078 (Rev. 03/05)


19. National Drug Code (11 digits) 20. Days� Supply Requested**

21. Wisconsin Medicaid Provider Identification Number (Eight digits)

22. Date of Service (MM/DD/YYYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up tofourteen days in the past.)

23. Place of Service (Patient Location) (Use patient location code �00� [Not specified], �01� [Home], �04� [Long Term / Extended Care],�07� [Skilled Care Facility], or �10� [Outpatient])

24. Assigned PA Number (Seven digits)

25. Grant Date 26. Expiration Date 27. Number of Days Approved


28. Include any additional information in the space below. For example, providers may include that this PA request is being submitted for a recipient who was granted retroactive eligibility by Wisconsin Medicaid, BadgerCare, or SeniorCare.

*PPI-approved codes are:

E9356 NSAID induced gastric ulcer NSAID induced duodenal ulcer4186 H. Pylori infection2515 Zollinger-Ellison syndrome53019 Erosive esophagitis53081 Gastroesophageal reflux (GERD)5368 Gastric hypersecretory conditions

**Days� supply requested equals the total number of days requested for the PA. For example, for a one-year PA, providers should enter�365.�

new preferred drug list information for dispensing providers · for proton pump inhibitor drugs the...

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