|Program Name: ||BadgerCare Plus and Medicaid ||Handbook Area: ||Pharmacy |
Reimbursement : Amounts
Maximum allowable fee information is available on the Max Fee Schedules page of the ForwardHealth Portal in the following forms:
- An interactive maximum allowable fee schedule
- Downloadable fee schedules by service area only in TXT or CSV files
Policy information is not displayed in the fee schedules. Providers should refer to their specific service area in the Online Handbook for more information about coverage policy related to a specific procedure code.
Certain fee schedules are interactive. On the interactive fee schedule, providers have more search options for looking up some coverage information, as well as the maximum allowable fees, as appropriate, for reimbursable HCPCS, CPT, or CDT procedure codes for most services.
Providers have the ability to independently search by:
- A single HCPCS, CPT, or CDT procedure code
- Multiple HCPCS, CPT, or CDT procedure codes
- A pre-populated code range
- A service area (Service areas listed in the interactive fee schedule more closely align with the provider service areas listed in the Online Handbook, including the WCDP programs and WWWP.)
The downloadable fee schedules, which are updated monthly, provide basic maximum allowable fee information by provider service area.
Through the interactive fee schedule, providers can export their search results for a single code, multiple codes, a code range, or by service area. The export function of the interactive fee schedule will return a zip file that includes seven CSV files containing the results.
Note: The interactive fee schedule will export all associated information related to the provider's search criteria except the procedure code descriptions.
Providers may call Provider Services in the following cases:
- The ForwardHealth Portal is not available.
- There is uncertainty as to which fee schedule should be used.
- The appropriate fee schedule cannot be found on the Portal.
- To determine coverage or maximum allowable fee of procedure codes not appearing on a fee schedule.
Drug Search Tool
The Drug Search Tool is designed to help users to identify and calculate ingredient reimbursement rates of drugs covered by BadgerCare Plus, Medicaid, SeniorCare, and WCDP. Covered drugs and reimbursement rate information is updated regularly.
Wisconsin Medicaid-enrolled pharmacies and other health care providers can use the drug search tool to help identify and calculate ingredient rates of drugs. Information provided through the drug search tool does not guarantee coverage or payment. Instructions for using the Drug Search Tool can be found in the Max Fee User Guide.
ForwardHealth will periodically update the information on the drug search tool.
Information Included in the Drug Search Tool
For each NDC and label name listed on the Drug Search Tool, the following information is available:
- Age restrictions associated with the NDC
- Copayment amount (brand, generic, compound, or not applicable)
- Diagnosis code restrictions
- Effective date of the listed ingredient rate
- Indicator for whether the NDC can only be billed as a compound drug ingredient
- Maximum days' supply permitted in one dispensing (34 or 100 days)
- The package size used to derive a unit price (It is the usual labeled quantity from which the pharmacist dispenses, such as 100 tablets, 1,000 capsules, or 20 mL vials.)
- The reimbursement methodology applicable to the prescription
- Unit of measurement, or drug form that indicates the basic drug measurement unit for performing price calculations (This includes valid values are for each [tablets, kits, etc.], milliliters [liquids], or grams [solids].)
- NDC unit rate and package rate
- PA requirements
For drugs included on the PDL, information on the Drug Search Tool will also include:
- The PDL dug class
- A list of all preferred drugs associated with the same PDL drug class as the selected NDC.
- The drug's PDL status (preferred or non-preferred).
Note: Reimbursement information for drugs purchased through the 340B Program is not available on the Drug Search Tool. HRSA maintains the official 340B ceiling prices, which are not available to the public due to confidentiality protections.