DHS 109.17 NoteNote: A hearing request should be mailed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI, 53707-7875. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or transmitted by facsimile machine to 608-264-9885.

DHS 109.31(1)(1) Covered services. Drugs and drug products covered under this chapter include prescription drugs and insulin listed in the Wisconsin medical assistance drug index that are prescribed by a physician licensed under s. 448.04, Stats., by a dentist licensed under s. 447.04, Stats., by a podiatrist licensed under s. 448.04, Stats., by an optometrist licensed under ch. 449, Stats., or by a nurse prescriber under ch. N 8, or when a physician delegates prescription of drugs to a nurse practitioner or to a physician’s assistant certified under s. 448.04, Stats., and the requirements under s. N 6.03 for nurse practitioners and under s. Med 8.07 for physician assistants are met. The limitations on coverage and services in this section apply to co-pay, spend-down and deductible.

DHS 109.31(2)(a)2.2. Drugs that have been demonstrated to entail significant expense or overuse for the medical assistance program. These drugs shall be noted in the Wisconsin medical assistance drug index.

DHS 109.31(2)(a)3.3. Drugs identified by the department that may be used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.

DHS 109.31(2)(b)1.1. In considering a prior authorization request under this chapter made by a provider under sub. (1), the department shall require the information required in s. DHS 107.02 (3) (d) and apply the review criteria in s. DHS 107.02 (3) (e).

DHS 109.31(2)(b)2.a.a. If a SeniorCare provider under sub. (1) does not request and obtain prior authorization before providing a prescription drug requiring prior authorization, the department may not provide reimbursement except in an emergency.

DHS 109.31(2)(b)2.b.b. Except in an emergency case as specified under subd. 2. a., the department may not cover a prescription drug or apply a participant’s purchase to the deductible or spend-down if the department has not prior authorized a drug requiring prior authorization. A certified provider may not hold a recipient liable for payment for a covered service requiring prior authorization by the department unless the department denies the prior authorization request and the provider informs the recipient of the recipient’s personal liability before provision of the service. If the department denies the recipient’s prior authorization request, the recipient may request a fair hearing under s. DHS 109.63. SeniorCare providers are required to request prior authorization for all SeniorCare participants.

DHS 109.31(3)(a)(a) SeniorCare providers shall limit dispensing of schedule III, IV and V drugs to the original dispensing plus 5 refills, or 6 months from the date of the original prescription, whichever comes first.

DHS 109.31(3)(b)(b) SeniorCare providers shall limit dispensing of non-scheduled legend drugs and insulin to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.

DHS 109.31(3)(c)1.1. Generically-written prescriptions for drugs listed in the federal food and drug administration approved drug products publication with a generic drug included in that list.

DHS 109.31(3)(c)2.2. Prescription orders written for brand name drugs that have a lower cost generically available drug with the lower cost drug product, unless the prescribing provider under sub. (1) writes “brand medically necessary” on the face of the prescription. The prescribing provider shall document in the patient’s record the reason why the drug is medically necessary.

DHS 109.31(3)(e)(e) SeniorCare providers may dispense certain maintenance drugs specified under s. DHS 107.10 (3) (e), in amounts up to but not to exceed a 100-day supply, as prescribed by a physician.

DHS 109.31 NoteNote: The maintenance drugs listed in section DHS 107.10 (3) (e) are: digoxin, digitoxin, digitalis; hydrochlorothiazide and chlorothiazide; prenatal vitamins; fluoride; levothyroxine, liothyronine and thyroid extract; phenobarbital; phenytoin; and oral contraceptives.

DHS 109.31 NoteNote: Par. (e) is amended by 2023 Wis. Act 71 as shown below, effective upon approval by the federal secretary of health and human services of a waiver or amendment to a waiver requested under Section (3) of 2023 Wis. Act 71. If the waiver or amendment to a waiver requested under Section 3 is denied, the amendment by 2023 Wis. Act 71, as shown below, is void.

DHS 109.31 Note(e) SeniorCare providers may dispense certain maintenance drugs specified under s. DHS 107.10 (3) (e) or any other drug, as determined by the department on the basis of clinical considerations, safety, costs, and other factors, in amounts up to but not to exceed a 100-day supply, as prescribed by a physician.