Section 109.31. Covered drugs and limitations on coverage.

 

(1)   Covered services. Drugs and drug products covered under this chapter include prescription drugs and insulin listed in the Wisconsin medical assistance drug index that are prescribed by a physician licensed under s. 448.04 , Stats., by a dentist licensed under s. 447.04 , Stats., by a podiatrist licensed under s. 448.04 , Stats., by an optometrist licensed under ch. 449 , Stats. , or by a nurse prescriber under ch. N 8 , or when a physician delegates prescription of drugs to a nurse practitioner or to a physician's assistant certified under s. 448.04 , Stats., and the requirements under s. N 6.03 for nurse practitioners and under s. Med 8.07 for physician assistants are met. The limitations on coverage and services in this section apply to co-pay, spend-down and deductible.

(2)   Prior authorization.

(a) Drugs requiring prior authorization. The following drugs and supplies require prior authorization:

1. All schedule III and IV stimulant drugs.

2. Drugs that have been demonstrated to entail significant expense or overuse for the medical assistance program. These drugs shall be noted in the Wisconsin medical assistance drug index.

3. Drugs identified by the department that may be used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.

(b) Request for prior authorization .

1. In considering a prior authorization request under this chapter made by a provider under sub. (1) , the department shall require the information required in s. DHS 107.02 (3) (d) and apply the review criteria in s. DHS 107.02 (3) (e) .

2.

a. If a SeniorCare provider under sub. (1) does not request and obtain prior authorization before providing a prescription drug requiring prior authorization, the department may not provide reimbursement except in an emergency.

b. Except in an emergency case as specified under subd. 2. a. , the department may not cover a prescription drug or apply a participant's purchase to the deductible or spend-down if the department has not prior authorized a drug requiring prior authorization. A certified provider may not hold a recipient liable for payment for a covered service requiring prior authorization by the department unless the department denies the prior authorization request and the provider informs the recipient of the recipient's personal liability before provision of the service. If the department denies the recipient's prior authorization request, the recipient may request a fair hearing under s. DHS 109.63 . SeniorCare providers are required to request prior authorization for all SeniorCare participants.

(3)   Other limitations.

(a) SeniorCare providers shall limit dispensing of schedule III, IV and V drugs to the original dispensing plus 5 refills, or 6 months from the date of the original prescription, whichever comes first.

(b) SeniorCare providers shall limit dispensing of non-scheduled legend drugs and insulin to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.

(c) SeniorCare providers shall fill:

1. Generically-written prescriptions for drugs listed in the federal food and drug administration approved drug products publication with a generic drug included in that list.

2. Prescription orders written for brand name drugs that have a lower cost generically available drug with the lower cost drug product, unless the prescribing provider under sub. (1) writes "brand medically necessary" on the face of the prescription. The prescribing provider shall document in the patient's record the reason why the drug is medically necessary.

(d) Except as provided in par. (e) , SeniorCare providers shall dispense prescription drugs in amounts not to exceed a 34-day supply.

(e) SeniorCare providers may dispense certain maintenance drugs specified under s. DHS 107.10 (3) (e) , in amounts up to but not to exceed a 100-day supply, as prescribed by a physician.

(f) The only general category of over-the-counter drugs that shall be covered are the insulins.

(g) The innovator of a multiple-source drug shall be a covered service only when the prescribing provider under sub. (1) certifies by writing the phrase "brand medically necessary" on the prescription.

(4)   Lock-in program.

(a) Required when program is abused. If the department discovers that a participant is abusing the program, including the type of abuse under s. DHS 109.61 (1) and (5) , the department may require the participant to designate one pharmacy as the SeniorCare lock-in provider of the participant's choice.

(b) Selection of lock-in provider. The department shall allow a participant to choose a lock-in provider from the department's current list of certified SeniorCare providers. The participant's choice shall become effective only with the concurrence of the designated lock-in provider.

(c) Failure to cooperate. If the participant fails to designate a lock-in provider within 15 days after receiving a formal request from the department, the department shall designate a lock-in provider for the participant.

(5)   Non–covered services. In addition to possible non-coverage without prior authorization of some drugs under sub. (2) (b) 2. , the following drugs are not covered under this chapter:

(a) A drug not covered under the medical assistance program under s. DHS 107.10 (4) .

(b) A drug produced by a manufacturer who has not entered into a rebate agreement with the department, as required by s. 49.688 , Stats.

(6)   Drug review, counseling and recordkeeping.

(a) In addition to complying with ch. Phar 7 , a SeniorCare provider shall do all of the following:

1. Provide for a review of drug therapy before each prescription is filled or delivered to a SeniorCare participant. The review shall include screening for potential drug therapy problems including therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions and clinical abuse or misuse.

2. Offer to discuss with each SeniorCare participant, the participant's legal representative or the participant's caregiver who presents the prescription, matters which, in the exercise of the SeniorCare provider's professional judgment and consistent with state statutes and rules governing provisions of this information, the SeniorCare provider deems significant, including the following:

a. The name and description of the medication.

b. The route, dosage form, dosage, route of administration, and duration of drug therapy.

c. Specific directions and precautions for preparation, administration and use by the patient.

d. Common severe side effects or adverse effects or interactions and therapeutic contraindications that may be encountered, including how to avoid them, and the action required if they occur.

e. Techniques for self-monitoring drug therapy.

f. Proper storage.

g. Prescription refill information.

h. Action to be taken in the event of a missed dose.

3. Make a reasonable effort to obtain, record and maintain at least the following information regarding each SeniorCare participant for whom the SeniorCare provider dispenses drugs under the SeniorCare program:

a. The participant's name, address, telephone number, date of birth or age and gender.

b. The participant's medical history where significant, including any disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices.

c. The SeniorCare provider's comments related to the participant's drug therapy.

(b) Nothing in this subsection shall be construed as requiring a SeniorCare provider to provide consultation when a SeniorCare participant, the participant's legal representative or the participant's caregiver refuses the consultation.

CR 02-154 : cr. Register April 2003 No. 568 , eff. 5-1-03; corrections in (2) (b), (3) (e) and (5) (a) made under s. 13.92 (4) (b) 7. , Stats., Register December 2008 No. 636 ; correction in (1) made under s. 13.92 (4) (b) 7. , Stats., Register February 2014 No. 698 .

Note

The maintenance drugs listed in section DHS 107.10 (3) (e) are: digoxin, digitoxin, digitalis; hydrochlorothiazide and chlorothiazide; prenatal vitamins; fluoride; levothyroxine, liothyronine and thyroid extract; phenobarbital; phenytoin; and oral contraceptives. Microsoft Windows NT 6.1.7601 Service Pack 1