Medicine and Surgery Section - Wisconsin.gov

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Prescription Requirements prescriber has indicated a 100-day supply quantity on the prescription. Prescription Mail Delivery Current Wisconsin law permits Wisconsin Medicaid-certified retail pharmacies to deliver prescriptions to recipients via the mail. Wisconsin Medicaid-certified retail pharmacies may dispense and mail any prescription or OTC medication to a Medicaid fee-for-service recipient at no additional cost to the recipient or Wisconsin Medicaid. Providers are encouraged to use the mail delivery option if requested by the recipient, particularly for prescriptions filled for a 100day supply. Noncovered Drugs The following drugs are not covered by Wisconsin Medicaid: • Drugs that are identified by the Food and Drug Administration as less-than-effective (LTE) or identical, related, or similar to LTE drugs. • Drugs identified on the Wisconsin Negative Formulary. • Drugs manufactured by companies who have not signed the rebate agreement. SeniorCare Wisconsin SeniorCare is a prescription drug assistance program for Wisconsin residents who are 65 years of age or older and meet eligibility criteria. Wisconsin SeniorCare is modeled after Wisconsin Medicaid in terms of drug coverage and reimbursement, although there are a few differences. Unlike Wisconsin Medicaid, SeniorCare does not cover OTC drugs other than insulin. Refer to the SeniorCare section of the Pharmacy Handbook or the SeniorCare Web site at dhfs.wisconsin.gov/seniorcare/ for more information. Epocrates Providers may also access the Medicaid and SeniorCare PDL through Epocrates. Epocrates’ products provide clinical reference information specifically for health care providers to use at the point of care. Prescribers and dispensing providers (e.g., pharmacies, dispensing physicians, federally qualified health centers, blood banks) who use personal digital assistants can subscribe and download the PDL by accessing the Epocrates Web site at www2.epocrates.com/. Disposable Medical Supplies and Durable Medical Equipment All durable medical equipment (DME) and disposable medical supplies (DMS) require a physician or physician assistant prescription signed and dated by the prescriber except for the following DMS: • Hearing instrument accessories. • Hearing instrument batteries. • Hearing instrument repairs. Prescribers are reminded that they are required to determine that all DME and DMS items are medically necessary before a prescription is written. Refer to the medical supply provider and medical equipment vendor publications on the Medicaid Web site for more information on DMS and DME coverage and limitations. Breast Pumps Wisconsin Medicaid reimburses for the prescribing of breast pumps as part of an evaluation and management office visit. Physicians are required to document clinical requirements of an individual’s need for a breast pump. Wisconsin Medicaid requires the following criteria be met: • The recipient recently delivered a baby and a physician has ordered or recommended mother’s breast milk for the infant. • Documentation indicates there is the potential for adequate milk production. 52 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 Prescribers are reminded that they are required to determine that all DME and DMS items are medically necessary before a prescription is written.
Wisconsin Medicaid requires a prescription for specialized medical vehicle (SMV) trips that exceed Wisconsin Medicaid’s oneway mileage limits. • Documentation indicates there is a longterm need for and planned use of the breast pump to obtain a milk supply for the infant. • The recipient is capable of being trained to use the breast pump as indicated by the physician or provider. • Current or expected physical separation of mother and infant (e.g., illness, hospitalization, work) would make breastfeeding difficult, or there is difficulty with “latch on” due to physical, emotional, or developmental problems of the mother or infant. The optional Breast Pump Order, HCF 1153, is located in Appendix 14 of this section and may also be downloaded and printed from the Medicaid Web site. Physicians or nurse practitioners may prescribe breast pumps for recipients that can then be obtained through a Medicaid-certified DME provider or pharmacy. Wisconsin Medicaid does not reimburse prescribing providers for supplying breast pumps, unless they are also Medicaid certified as a medical equipment vendor or a pharmacy. Specialized Medical Vehicle Trips Exceeding Mileage Limits Wisconsin Medicaid requires a prescription for specialized medical vehicle (SMV) trips that exceed Wisconsin Medicaid’s one-way mileage limits. In addition to a prescription, a completed Certification of Need for Specialized Medical Vehicle Transportation form, HCF 1197, is also required. The completion instructions and Certification of Need for Specialized Medical Vehicle Transportation form are located in Appendix 28 of this section and may also be downloaded and printed from the Medicaid Web site. A medical care provider referring an SMVeligible recipient to a Medicaid-covered health service that is farther than the upper mileage limit must write a prescription for the recipient to give to the SMV provider. Wisconsin Medicaid one-way upper mileage limits are: • 40 miles or more, if the trip originates in one of these urban counties: Brown Milwaukee Dane Outagamie Fond du Lac Sheboygan Kenosha Racine La Crosse Rock Manitowoc Winnebago • 70 miles or more, if the trip originates in any other Wisconsin county. The prescription must be renewed upon expiration and must include the following: • Name of the health care provider or facility and the city in which it is located. • The service being provided. • The length of time the recipient will need the service (not to exceed 365 days). For more information about SMV services, refer to the General Information chapter of this section. Physician Services Handbook — Medicine and Surgery December 2005 53 Prescription Requirements
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Appendix Health Professional Shorta
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Appendix HPSA Name County ZIP Codes
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Appendix The following table lists
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DECLARATION OF SUPERVISION FOR NONB
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Appendix HCPCS Code* Drug Name Diag
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Index Organ Transplants, 44 Provide
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Medicine and Surgery Section - Wisconsin.gov

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