Covered and Noncovered Services : Covered Services and Requirements

Drugs With a Three-Month Supply Maximum

For three-month supply drugs, the following apply:

• Certain drugs are required to be dispensed in a three-month supply.
• Additional drugs are allowed to be dispensed in a three-month supply.

Dispensing a three-month supply of drugs streamlines the prescription filling process for pharmacy providers, encourages the use of generic, maintenance drugs when medically appropriate for a member, and results in savings to ForwardHealth programs.

Drugs Required to Be Dispensed in a Three-Month Supply

ForwardHealth has identified a list of drugs for which pharmacy providers will be required to dispense a three-month supply.

Claims for drugs required to be dispensed in a three-month supply will be denied with an EOB text and an NCPDP reject code.

Pharmacy providers will be required to call the DAPO Center to request a policy override to dispense less than a three-month supply. ForwardHealth may authorize dispensing of less than a three-month supply for up to one year. Pharmacy providers may request an override to dispense less than a three-month supply for members enrolled in BadgerCare Plus, Medicaid, and SeniorCare.

Examples of when a request for a policy override to dispense less than a three-month supply may be approved include, but are not limited to, the following:

• The member's primary insurance does not allow a three-month supply.
• The prescriber or pharmacist is concerned about dispensing a three-month supply to a member.

Pharmacy providers may dispense up to a 96-hour supply of a drug to a member when the DAPO Center is closed and a policy override to dispense less than a three-month supply must be obtained. If the DAPO Center grants a policy override for less than a three-month supply, the policy override will be retroactive and the pharmacy provider may submit a claim for the drug. If the claim for a 96-hour supply is submitted on paper, the pharmacy provider will be required to complete and submit a Pharmacy Special Handling Request form. Providers should check Element 4 (Policy Review Request) and provide this statement in the space provided: 96-hour policy override for a three-month supply.

If the DAPO Center denies the policy override, ForwardHealth will reimburse the provider for the 96-hour supply. A claim must be submitted on paper with the Pharmacy Special Handling Request. Providers should check Element 4 (Policy Review Request) and provide an explanation of the review needed (for example, 96-hour policy override for early refill) in the space provided.

The 14-day emergency medication dispensing policy does not apply to the three-month supply policy.

Drugs Allowed to Be Dispensed in a Three-Month Supply

For drugs that are allowed to be dispensed in a three-month supply, but are not required to be, pharmacy providers should work with the member and the prescriber to determine whether or not it is clinically appropriate to dispense a three-month supply. Claims for these drugs will not be denied regarding the informational prospective DUR alert for insufficient quantity (NS or three-month supply). Providers will receive the informational claim message "Three Month Supply Opportunity" on claims for these drugs.

Unbreakable Pre-Packaged Items

If a claim is submitted for an unbreakable pre-packaged item with directions for use that are greater than the allowable maximum of a 34-day supply and the drug is not listed on the Three-Month Supply of Drugs data table, use the smallest available package size and indicate a 34-day supply.

Prescriber Responsibilities for Three-Month Supply Drugs

For drugs that are required to be dispensed in a three-month supply, prescribers must indicate a three-month supply (for example, a quantity of 90 or 100) on the prescription to allow the pharmacy provider to dispense maintenance drugs in quantities up to a three-month supply. For example, if the prescription is written for "Hydrochlorothiazide 25 mg, take one tablet daily," the prescriber is required to indicate a quantity of 90 or 100 tablets on the prescription so the pharmacy provider can dispense a three-month supply.

For drugs required to be dispensed in a three-month supply, once a member has been stabilized on a drug as evidenced by use of the same drug strength and dosage form for 90 days of the past 120 days, refills of the same drug strength and dosage form must be dispensed in a three-month supply. If the member previously has been dispensed a three-month supply of a drug of the same strength and dosage form, a three-month supply must be dispensed.

If a member has not previously been dispensed a three-month supply of a drug of the same strength and dosage form, but has been stabilized on that drug, the prescriber must write a prescription so the pharmacy provider can dispense a three-month supply of the drug.

Pharmacy Responsibilities for Three-Month Supply Drugs

According to Wis. Admin. Code § DHS 107.10(3)(e), providers are required to dispense all legend drugs in the full quantity prescribed, not to exceed a 34-day supply, except for drugs that may be dispensed in a three-month supply and those required to be dispensed in a three-month supply.

If a prescription is written for a drug that is required to be dispensed in a three-month supply, the pharmacy provider should determine if the member has been stabilized on the drug.

If the member has not been stabilized on the drug, a quantity not to exceed a 34-day supply should be dispensed. If the member has been stabilized on the drug, the pharmacy provider must work with the prescriber to obtain a prescription for a three-month supply or obtain a policy override to dispense less than a three-month supply.

Prescription Quantity

A prescriber must indicate a sufficient quantity on prescription orders to allow pharmacy providers to dispense a three-month supply of drugs that are required to be dispensed in a three-month supply.

Pharmacy providers must work with prescribers to make certain the total quantity of a drug dispensed per a prescription order does not exceed the total quantity of the drug authorized by the prescriber on the prescription order.

ForwardHealth will not audit or recoup three-month supply claims if a pharmacy provider changes a prescription written as a one-month supply with refills as long as the total quantity dispensed per prescription does not exceed the total quantity authorized by the prescriber.

Member Benefits

A three-month supply of a drug may benefit a member in the following ways:

• Aiding compliance in taking prescribed generic, maintenance medications
• Reducing the cost of member copays
• Requiring fewer trips to the pharmacy
• Allowing the member to obtain a larger quantity of generic, maintenance drugs for chronic conditions (for example, hypertension)

Service Limitations

If an override of a service limitation, such as a three-month supply policy override, is requested and the request does not meet service limitation override criteria, the policy override will be denied and the service will be a noncovered service.

In addition, if one of the following circumstances is met, a three-month supply of a drug is a noncovered service:

• If the member does not accept a three-month supply or the member perceives a safety concern with a drug and does not accept a three-month supply. (Note: If a member's primary insurance does not allow a three-month supply to be dispensed, a drug dispensed in less than a three-month supply is a covered service.)
• If the prescriber is not enrolled in Wisconsin Medicaid and is unwilling to approve a three-month supply or does not provide a valid reason for a three-month supply to be dispensed.
• If the prescriber is enrolled in Wisconsin Medicaid, but the prescriber does not approve a three-month supply or does not provide a valid reason for a three-month supply to be dispensed. (Note: Pharmacy providers should contact the DAPO Center for additional instructions in this instance.)

Pharmacy providers enrolled in BadgerCare Plus, Medicaid, and SeniorCare may collect payment from members in the previously listed circumstances.

With the exception of previously described policies, pharmacies cannot collect payment from members for a three-month supply of a drug if the pharmacy provider does not follow the policies described above.

Members do not have appeal rights for noncovered drugs or service.

Drugs for Nursing Facility Members

If a member is in a nursing facility, providers should indicate the appropriate place of service code on the claim. This will exempt the member from the three-month supply of drugs policy. When serving a member in a nursing facility, pharmacy providers are not required to contact the DAPO Center to obtain an override to dispense less than a three-month supply of drugs.