Covered and Noncovered Services : Covered Services and Requirements

Contraceptives

Age restrictions and quantity limits for certain contraceptives apply to members enrolled in BadgerCare Plus, Wisconsin Medicaid, and Family Planning Only Services.

Age Restrictions

Age restrictions apply to certain contraceptives.

Contraceptives are covered for members who are 10 through 65 years of age.

Quantity Limits

Quantity limits apply to certain contraceptives.

Claims that exceed the quantity limit are denied with an EOB code.

Providers are encouraged to dispense up to a three-month supply of contraceptives, for which a quantity limit applies. However, members should be stabilized on the drug for at least 90 days. 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.

Duplicate Claims

Claims are denied as duplicate claims if a claim for the same contraceptive was reimbursed by ForwardHealth and the quantity allowed on the initial claim and the quantity billed on the current claim together exceed the allowed quantity limit.

If a claim is denied as a duplicate, and the member meets one of the following criteria, pharmacy providers should resubmit the claim and a completed Written Correspondence Inquiry form with an explanation to ForwardHealth. Examples of when duplicate claims will be reimbursed by Wisconsin Medicaid include, but are not limited to, the following:

• If the member has an appropriate medical need (for example, the member's medications were lost or stolen, the member has requested a vacation supply)
• If the member experienced a medical problem while taking one contraceptive and was switched to another contraceptive
• If the prescriber changed the directions for administration of the drug and did not inform the pharmacy provider