Effective for dates of service on and after January 1, 2020, the Wisconsin Department of Health Services will carve out coverage of most prescription outpatient drugs from the Family Care Partnership benefit. This change ensures MCOs’ compliance with the Managed Care Rule and eliminates the need for the MCOs to implement their own DUR program. For Family Care Partnership members who are not enrolled in Medicare, claims for outpatient drugs (excluding diabetic supplies), provider-administered drugs, compound drugs (including parenteral nutrition), and any other drugs requiring DUR will be submitted to and reimbursed by fee-for-service Medicaid.
Note: Members who are dual eligibles (enrolled in Medicare and Medicaid) will continue to receive their outpatient drugs through their Medicare Part D plans. However, if the member’s Part D plan does not cover the outpatient drug, these dually eligible members may access certain Medicaid outpatient drugs that are excluded or otherwise restricted from Medicare coverage through fee-for-service Medicaid. For these drugs, fee-for-service policies would apply.
The following resources and references are available to help with the drug carve-out transition.
For assistance determining drug coverage policy and limitations, refer to the:
For assistance with complex billing and claims processing questions, contact the Provider Relations Field Representatives.
ForwardHealth Member Services: For members’ questions regarding Medicaid enrollment, coverage, or other member-specific issues
Aging and Disability Resource Centers (ADRCs): For members who have questions about Partnership enrollment, disenrollment, or eligibility
Assistance for Partnership members: For members who have concerns with their MCO, including information regarding filing a complaint
Family Care Partnership program: For general member information regarding the Family Care Partnership program
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