| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Pharmacy | | 05/08/2024 | Prior Authorization : Diagnosis-Restricted DrugsTopic #15537 Diagnosis-Restricted Drugs
Prescribers are required to indicate a diagnosis on prescriptions for all drugs that are identified by ForwardHealth as diagnosis-restricted. If a diagnosis is not indicated on the prescription, pharmacy providers should contact the prescriber to obtain the diagnosis and document the diagnosis on the prescription or pharmacy health care record. It is not acceptable for pharmacy providers to obtain the diagnosis from the member.
The diagnosis submitted on a claim must also be verifiable within the member's prescription record or pharmacy health care record. Upon retrospective review, ForwardHealth may seek recoupment for the payment of the prescription from the pharmacy if the prescription record or pharmacy health care record does not document that the diagnosis submitted on the claim was provided by the prescriber.
Refer to the Diagnosis Restricted Drugs data table for a list of diagnosis-restricted drugs.
Prescribers are required to complete the appropriate section(s) of the PA/DGA as it pertains to the drug being requested. |