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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
5.16.16.3 Out-of-state Pharmacies
For all of the participation levels, SC allows the following:
The generic form of any covered prescription drug, unless the medical practitioner writes on the prescription that the brand name form of the covered prescription drug is medically necessary.
Insulins are the only general category of over-the-counter drugs that are covered.
For levels 1 and 2a all prescription drugs covered by Medicaid. Some limitations apply to prescription drug coverage for levels 2b and 3 if a rebate agreement has not been signed by the drug manufacturer.
Chemotherapy drugs that are FDA approved and the manufacturer has signed a rebate agreement.
Reimbursement for most drugs is limited to a 34-day supply. Some maintenance drugs may be provided in a 100-day supply.
The co-payment amount is not affected by the # of days in the supply.
NOTE : The participant should contact his/her provider to verify that SC covers a specific drug.
SC does not cover the following:
Prescription drugs administered in a physician’s office.
Prescription drugs that are experimental or have a cosmetic, not a medical purpose.
Over-the-counter drugs (except for insulin) such as vitamins or aspirin, prilosec OTC, even with a prescription.
Prescription drugs for which prior authorization has been denied.
Colostomy supplies and other durable medical supplies (DMS) even though they may need a prescription.
Prescription drugs for participants in Levels 2b and 3 for which a rebate agreement has not been signed by the manufacturer.
The discount for a particular drug during the deductible period will be the same at every pharmacy. During the deductible period, the pharmacy must use the SC allowed price.
Exception: If a pharmacy’s usual and customary charge is less than the SC allowed amount, then the participant would be charged the usual and customary charge and this amount will apply to SC spenddown and/or deductible.
When the participant is temporarily leaving the state and the supply on his/her prescriptions is insufficient, s/he will need to make arrangements with the pharmacist to have any additional refills mailed or have someone else pick-up the refill. Postage costs are not covered by SC nor do they count toward the deductible and/or spenddown. Requests for early refills will be denied.
In an emergency, a participant can get a prescription filled out of state and have it count toward SC as long as the participant is within the US, Canada, or Mexico and the pharmacy completes the necessary forms.
Out-of-state pharmacies should contact 1-800-947-9627 to file a claim for reimbursement. Non-emergency prescriptions will be covered only when prior authorization has been granted.
This page last updated in Release Number: 04-02
Release Date: 04/30/04
Effective Date: 04/30/04