Medicine and Surgery Section - Wisconsin.gov

Prescription
Requirements
Prescriber Responsibilities for Non-
Preferred Drugs
If a non-preferred drug is medically necessary,
the prescriber is required to complete the
appropriate Prior Authorization/Preferred Drug
List (PA/PDL) form and submit it to the
dispensing provider. The PA/PDL form allows
the prescriber to document that the recipient
meets one of the clinical criteria requirements
for PA approval. The completion instructions
and PA/PDL forms may be downloaded and
printed from the Medicaid Web site. Providers
may also call Provider Services to obtain a
paper copy of the forms.
Clinical criteria for approval of a PA request
for a non-preferred drug must include one of
the following:
• A treatment failure with a preferred drug.
• A condition that prevents the use of a
preferred drug(s).
• A clinically significant drug interaction with
another medication and a preferred
drug(s).
• An intolerable side effect experienced
while the recipient is taking a preferred
drug(s).
If the recipient’s condition does not meet one
of the clinical criterion, a paper PA request and
peer-reviewed medical literature must be
submitted to Wisconsin Medicaid, not the
dispensing provider.
Prescribers are required to complete a new
PA/PDL form for each non-preferred drug
and provide enough clinical information so that
dispensing providers can request and obtain PA
both for new prescriptions and for refills on
existing prescriptions for non-preferred drugs.
If a PA/PDL form is not sent to the dispensing
provider for an existing prescription of a nonpreferred
drug or does not accompany a new
prescription for a non-preferred drug, the
dispensing provider must contact the prescriber
to obtain a completed copy of the form.
Prescribers may choose to change the
prescription to a preferred drug if medically
appropriate for the recipient.
A completed PA/PDL form may be sent by
mail or fax to the dispensing provider where
the prescription will be filled, or the prescriber
may send a completed copy of the form with
the recipient to the dispensing provider.
Prescribers should not send prescription drug
PA forms directly to Wisconsin Medicaid. The
dispensing provider will use the completed
form to submit a PA request to Wisconsin
Medicaid. Prescribers and dispensing providers
are required to retain a completed copy of the
form. Refer to the Forms page of the Medicaid
Web site for PA/PDL forms.
Step Therapy for Proton Pump Inhibitor
Drugs
Proton Pump Inhibitor (PPI) drugs on the PDL
require step therapy. Step therapy requires that
a recipient try and fail one or more preferred
drugs before obtaining PA for a non-preferred
drug. The preferred PPI drug is Prilosec
OTC ® .
Approval of a PA request for a non-preferred
PPI drug can only occur in one of the
following situations:
• The recipient has trial and failure of or
adverse reaction to a preferred PPI drug.
• The recipient is a child weighing less than
20 kilograms (44 lbs).
• The recipient is a pregnant woman.
Refer to the Forms page of the Medicaid Web
site for step therapy instructions for PPI drugs
and the appropriate PA/PDL form.
Step Therapy for Non-Steroidal Anti-
Inflammatory Drugs
Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs) on the PDL require the use of step
therapy. Step therapy requires that a recipient
48 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
If a non-preferred
drug is medically
necessary, the
prescriber is
required to
complete the
appropriate Prior
Authorization/
Preferred Drug List
(PA/PDL) form and
submit it to the
dispensing
provider.