Covered and Noncovered Services : Covered Services and Requirements

Manufacturer Rebate Agreements

In accordance with the OBRA of 1990, also known as the Medicaid Drug Rebate Program, drug manufacturers who choose to participate in BadgerCare Plus, Medicaid, and SeniorCare are required to sign a rebate agreement with the federal government.

BadgerCare Plus, Medicaid, and SeniorCare cover only the legend drugs of manufacturers who have signed rebate agreements. Non-participating manufacturers may sign rebate agreements that are effective the following quarter.

Claims for physician-administered drugs that do not have a signed manufacturer rebate agreement on file will be denied.

Manufacturer rebates are based on claims data showing the quantity of each NDC dispensed to members. Manufacturers may dispute the payment of drug rebates if they believe the utilization data reported to them is inaccurate. To resolve disputes, ForwardHealth verifies utilization data by having individual providers check the accuracy of claims information they submit.

Drugs by Manufacturers That Did Not Sign Rebate Agreements for Members Enrolled in BadgerCare Plus, Medicaid, or SeniorCare (Levels 1 and 2a)

BadgerCare Plus, Medicaid, and SeniorCare levels 1 and 2a may cover certain FDA-approved legend drugs through the PA process even though the drug manufacturers did not sign rebate agreements.

Prescribers are required to complete the appropriate section(s) of the PA/DGA form as it pertains to the drug being requested.

Included with the PA request, the prescriber must submit documentation of medical necessity and cost effectiveness that the non-rebated drug is the only available and medically appropriate product for treating the member. The documentation must include the following:

• A copy of the medical record or documentation of the medical history detailing the member's medical condition and previous treatment results
• Documentation by the prescriber that shows why other drug products have been ruled out as ineffective or unsafe for the member's medical condition
• Documentation by the prescriber that shows why the non-rebated drug is the most appropriate and cost effective drug to treat the member's medical condition

If a PA request for a drug without a signed manufacturer rebate is approved, claims for drugs without a signed rebate agreement must be submitted on paper. Providers should complete and submit the Noncompound Drug Claim form indicating the actual NDC of the drug with the Pharmacy Special Handling Request form.

If a PA request for a drug without a signed manufacturer rebate is denied, the service is considered noncovered.

Drugs by Manufacturers Without a Rebate Agreement for Members Enrolled in SeniorCare (Levels 2b and 3)

Existing federal Medicaid rebate agreements with drug manufacturers do not cover drugs for SeniorCare members with incomes greater than 200 percent of the FPL (levels 2b and 3). For these members, Wis. Stat. § 49.688(6) requires SeniorCare to cover drugs from only those manufacturers who have signed a separate SeniorCare rebate agreement with DHS. As a result, drugs supplied by manufacturers who have declined to enter into a separate SeniorCare rebate agreement will not be covered for members with incomes greater than 200 percent of the FPL. SeniorCare members in levels 1 or 2a (incomes less than 200 percent of the FPL) are not affected by this.

Availability of Covered Drugs

When a drug manufacturer's products are not covered for a member because the manufacturer has not signed a separate SeniorCare rebate agreement, providers who submit claims for a noncovered drug will be denied.

If a covered manufacturer for a drug exists and the member's pharmacy does not carry the drug, providers may choose to either stock the drug or refer the member to another pharmacy that stocks the drug. A pharmacy should not tell a member that the drug is not covered if it is available through another manufacturer.

Availability of Non-Reimbursable Drugs

A member in level 2b or 3 may make the decision to purchase a drug even though the drug is not reimbursable by SeniorCare. If the member chooses to do this, the pharmacy may collect payment from the member for the entire cost of the drug.

Providers and members should understand the following under these circumstances:

• The entire cost of the noncovered drug becomes the member's responsibility.
• If the member is in the spenddown or deductible period, any amount paid for noncovered drugs will not be applied toward the spenddown or deductible