Medicine and Surgery Section - Wisconsin.gov

Prescription
Requirements
Approval Criteria for Narrow Therapeutic
Index Drugs
For certain narrow therapeutic index drugs,
including Clozaril, Coumadin, Dilantin, Neoral
and Tegretol, an additional criteria of an
anticipated therapeutic failure is considered.
Documentation on the PA/BMNA must
include the prescriber’s belief that switching
the recipient to a generic drug is likely to cause
an adverse reaction.
Titration of Brand Medically Necessary
Drugs
Prescribers who titrate a brand medically
necessary drug for a recipient may request
more than one strength of the drug on the
PA/BMNA. Prescribers should include a
prescription for each strength of the titrated
brand medically necessary drug with the
PA/BMNA.
Prior Authorization Requirements
for Other Drugs
Although pharmacies are responsible for
obtaining PA for the following drugs that are on
the brand medically necessary list or the PDL,
prescribers (e.g., physicians, physician
assistants, nurse practitioners) may be asked to
provide clinical information to support the
medical necessity of the drug(s):
• Alpha-1 proteinase inhibitor (Prolastin and
Aralast).
• Angiotensin converting enzyme (ACE)
inhibitors.
• Anti-obesity drugs.
• Brand-name selective serotonin reuptake
inhibitor (SSRI) drugs. (Generic
citalopram, fluoxetine, and paroxetine do
not require PA.)
• C-III and C-IV stimulants.
Refer to the Medicaid Web site for more
information about these and other drugs.
Prescribing Drugs Manufactured by
Companies Who Have Not Signed
the Rebate Agreement
Drug manufacturers who choose to participate
in state Medicaid programs are required to sign
a rebate agreement with the federal Centers
for Medicare and Medicaid Services under the
drug rebate program. By signing the rebate
agreement, the manufacturer agrees to pay
Wisconsin Medicaid a rebate equal to a
percentage of its “sales” to Wisconsin
Medicaid.
Wisconsin Medicaid does not cover drugs of
companies choosing not to sign the rebate
agreement with few exceptions. A Medicaidcertified
pharmacy can confirm for prescribers
whether or not a particular drug manufacturer
has signed the agreement. In addition,
providers may refer to the Physician page of
the Medicaid Web site for a list of
manufacturers who have signed drug rebate
agreements.
Wisconsin Medicaid recognizes that there are
a few cases where it is medically necessary to
provide a drug that is produced by a
manufacturer who has not signed a rebate
agreement. These drugs may be reimbursed
when the pharmacy obtains PA.
In this situation, the prescriber is required to
provide the following documentation to the
pharmacy:
• A statement indicating that no other drug
produced by a manufacturer who signed
the rebate agreement is medically
appropriate for the recipient.
• A statement indicating that Medicaid
reimbursement of the drug would be cost
effective for Wisconsin Medicaid.
A recipient request for a particular drug is not
considered adequate justification for granting
approval without the prescriber documenting
medical necessity.
50 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
Wisconsin
Medicaid does not
cover drugs of
companies
choosing not to
sign the rebate
agreement with
few exceptions.