Covered and Noncovered Services : Covered Services and Requirements

Emergency Medication Dispensing

Emergency medication dispensing policy applies to members enrolled in BadgerCare Plus, Wisconsin Medicaid, and SeniorCare. Emergency medication dispensing options include standard emergency supply and expedited emergency supply. Standard emergency supply is an emergency medication dispensing option available for drugs not included in expedited emergency supply policy, which requires providers to submit a claim as a pharmacy special handling request. Expedited emergency supply is an emergency medication dispensing option available with a STAT-PA approval for certain drugs on the PDL and allows providers to submit their claim electronically through the real-time POS system.

Emergency medication dispensing options are intended to ensure members receive medically necessary covered drugs that have a PA restriction when the prescriber cannot be reached to discuss preferred drug options, therapeutic alternatives, or to complete the necessary PA form, and the pharmacist determines that the member should be taking the drug immediately. Drugs dispensed in emergency situations do not require PA. Emergency medication dispensing policy does not guarantee subsequent approval of a PA request for the drug dispensed. Members must meet all criteria for PA requests to be approved.

Note: Out-of-state providers may render emergency medical services to prevent death or serious impairment of the health of members as defined in Wis. Admin. Code § DHS 101.03(52). Out-of-state providers must be enrolled in Wisconsin Medicaid and may not utilize expedited emergency supply. Border-status providers follow the same policies as ForwardHealth providers.

Policy for Standard Emergency Medication Dispensing

Pharmacy providers may submit claims for standard emergency medication supplies of drugs that are not included in the expedited emergency supply process on the Noncompound Drug Claim form with a Pharmacy Special Handling Request form, if the prescriber cannot be reached and the pharmacist determines that the member should begin taking a medication immediately.

A standard emergency medication supply request overrides PA policies.

Providers are required to indicate specific details about why the standard emergency medication supply is being requested on the Pharmacy Special Handling Request. Providers are encouraged to submit supporting documentation with the request if necessary. Paper claims for standard emergency medication supplies submitted without detailed information supporting the request will be denied.

A paid standard emergency medication supply claim does not guarantee subsequent approval of a PA request for the drug dispensed. Members must meet all criteria for a PA request to be approved.

A standard emergency medication supply claim may provide up to a 14-day supply. If the drug being dispensed is for an unbreakable pre-packaged item with directions for use that are greater than the allowable maximum of a 14-day supply, use the smallest available package size and dispense up to a 34-day supply.

Completing and Submitting Claim Forms Correctly for Standard Emergency Supply

Providers are required to correctly complete the Pharmacy Special Handling Request form and the Noncompound Drug Claim form to receive the appropriate reimbursement for a standard emergency medication dispensing. Completed and detailed information must be indicated on the forms.

As indicated on the Pharmacy Special Handling Request form, providers should mail the completed Noncompound Drug Claim and Pharmacy Special Handling Request forms.

ForwardHealth is committed to reimbursing providers for standard emergency medication supplies as long as the claims are properly completed and submitted with a Pharmacy Special Handling Request form.

Policy for Expedited Emergency Supply of Drugs

The expedited emergency supply policy is an emergency medication dispensing option available for certain drugs on the PDL. A list of the drugs available by expedited supply may be found on the Expedited Emergency Supply Request Drugs data table.

ForwardHealth allows pharmacy providers to submit requests for an expedited emergency supply for certain drugs using the STAT-PA system and then submit a claim for the expedited emergency supply electronically through the real-time POS system. This eliminates the need to submit noncompound drug claims for expedited emergency supply drugs as a pharmacy special handling request.

Members will be limited to receiving two 14-day expedited emergency supply approvals of the same drug from one pharmacy provider within a six-month time period. A maximum of six expedited emergency supply requests per member regardless of drug or pharmacy provider may be approved in a six-month time period.

Expedited emergency supply requests will generally be approved for up to a 14-day supply; however, for certain drugs, expedited emergency supply requests may be approved for up to a 34-day supply or up to a 100-day supply.

For diagnosis-restricted drugs, a ForwardHealth-approved diagnosis code must be indicated on expedited emergency supply requests and claims. Expedited emergency supply requests and claims submitted without a ForwardHealth-approved diagnosis code will be considered noncovered services.

An approved expedited emergency supply request does not guarantee that a subsequent PA request will be approved. Members must meet all criteria for a PA request to be approved.

An approved expedited emergency supply request overrides PDL PA policies for certain drugs available through STAT-PA. Providers should refer to the Expedited Emergency Supply Request Drugs data table for a list of the drug names or drug classes allowed.

An approved expedited emergency supply request does not override PA polices, such as BMN, BBG, or PDL drugs not available through STAT-PA. The expedited emergency supply request does not override other policies, such as the member enrollment and noncovered service policies.

Drugs That Can Be Dispensed in up to a 14-Day Supply

For drugs that require PA that can be dispensed in up to a 14-day expedited emergency supply, a PA is not required to be in process when the first expedited emergency supply request is submitted.

If a second expedited emergency supply is necessary for a member, there must be a PA request for the drug submitted to ForwardHealth, and it must be in the process of being adjudicated. The second expedited emergency supply request may be approved if a PA request is in process for the same drug and strength and the PA is submitted by the pharmacy that submitted the first expedited emergency supply request.

If a PA request for the drug has been approved, the second expedited emergency supply request will not be approved.

Requests for a second expedited emergency supply request may be submitted seven to 21 days after the initial request was submitted. Second expedited emergency supply requests will not be approved if they are submitted before day seven or after day 21.

For example, if an initial expedited emergency supply request was submitted on March 4 and a PA request for the drug was submitted on March 7 and a second expedited emergency supply is necessary for the member because the PA request had not yet been adjudicated, the second expedited emergency request may be submitted on March 10 or as late as March 24.

Drugs That Can Be Dispensed in up to a 34-Day Supply

For drugs that can be dispensed in up to a 34-day expedited emergency supply, pharmacy providers may dispense the quantity indicated on the prescription, up to a 34-day supply, after an expedited emergency supply request has been approved; however, only one expedited emergency supply every six months will be allowed for those drugs.

Drugs That Can Be Dispensed in up to a 100-Day Supply

For drugs that can be dispensed in up to a 100-day expedited emergency supply, pharmacy providers may dispense the quantity indicated on the prescription, up to a 100-day supply, after an expedited emergency supply request has been approved; however, only one expedited emergency supply every six months will be allowed for those drugs.

Submitting Requests for an Expedited Emergency Supply Approval

Pharmacy providers are required to complete, sign and date the PDL for Expedited Emergency Supply Request form before a request for an expedited emergency supply is submitted.

Expedited emergency supply requests may only be submitted using the STAT-PA system. Expedited emergency supply requests cannot be submitted for future or past DOS.

The STAT-PA system will notify pharmacy providers if an expedited emergency supply request has been approved. After an expedited emergency supply request has been approved, the pharmacy provider may submit a claim for the drug through the real-time POS system.

Expedited emergency supply requests cannot be amended.