For Dates of Service Before October 1, 2011

Over-the-Counter Drugs

BadgerCare Plus and Wisconsin Medicaid

As required by the OBRA '90, the BadgerCare Plus Standard Plan, the BadgerCare Plus Benchmark Plan, the BadgerCare Plus Core Plan, the BadgerCare Plus Basic Plan, and Wisconsin Medicaid cover the generic products of specific categories of OTC drugs from manufacturers who have signed rebate agreements with CMS.

A written prescription from a prescriber is required in order for OTC drugs to be covered.

The estimated acquisition cost for OTC drugs is determined by applying a discount to the AWP as listed by First DataBank Inc., except for MAC list drugs.

As per DHS 107.10(3)(h), Wis. Stats., certain classes of OTC drugs are covered.

BadgerCare Plus Benchmark Plan, Core Plan, Basic Plan, and SeniorCare

The BadgerCare Plus Benchmark Plan, the BadgerCare Plus Core Plan for Childless Adults, and the BadgerCare Plus Basic Plan cover a limited number of OTC drugs. The BadgerCare Plus Benchmark Plan Product List and the BadgerCare Plus Core Plan Product List include covered OTC drugs.

As a reminder, with the exception of OTC insulin, SeniorCare does not cover OTC drugs.

HealthCheck "Other Services"

Additional OTCs may be covered for children 20 years of age or younger through HealthCheck "Other Services." If the OTC is covered through HealthCheck "Other Services," pharmacists must ensure there is verification the child received a comprehensive HealthCheck exam within the last 365 days. The member must have verification of the HealthCheck exam. This may be a completed HealthCheck card, verification of the date of the HealthCheck exam written on the prescription, or any document with the date of the HealthCheck exam and the provider's signature.

Covered Over-the-Counter Drugs

If the NDC for the medication dispensed is not covered and the medication is for a child who has had a HealthCheck exam, providers should refer to the following information.

Certain OTC drugs are covered without PA for children who have had a HealthCheck exam. Covered OTCs include the following:

• Antidiarrheals.
• Antifungals.
• Antiflatuents.
• Antiparasitics.
• Electrolyte Replacement.
• Ferrous sulfate and ferrous gluconate.
• Lactase products.
• Laxatives.
• Multivitamins.
• Topical protectants.

Other OTC drugs may be covered with PA. In that case, the pharmacy provider should complete PA forms and the following steps:

• Include a copy of the HealthCheck verification.
• Include a completed section II of the PA/DGA or a copy of the prescription.
• Select the "HealthCheck Other Services" checkbox in Element 1 of the PA/RF.
• Fax the form to (608) 221-8616 or mail it to the following address:

  ForwardHealth
  Prior Authorization
  Ste 88
  6406 Bridge Rd
  Madison WI 53784-0088

• If PA is approved, do all of the following:
  • Dispense the medication.
  • Submit the claim through the POS system or by using the 1500 Health Insurance Claim Form using the procedure code assigned on the PA/RF.

Providers may request to add an NDC to the list of covered OTC drugs by completing the Drug Addition Review Request form.