DHS 107.10(2)(b) (b) All schedules III and IV stimulant drugs;

DHS 107.10(2)(c) (c) Medically necessary, specially formulated nutritional supplements and replacement products, including enteral and parenteral products used for the treatment of severe health conditions such as pathologies of the gastrointestinal tract or metabolic disorders, as described in the MA provider handbooks and bulletins, but not including enteral nutrition products administered through a tube.

DHS 107.10(2)(d) (d) Drugs the department has determined entail substantial cost or utilization problems for the MA program. These drugs shall be noted in the Wisconsin medicaid drug index;

DHS 107.10(2)(e) (e) Any drug produced by a manufacturer who has not entered into a rebate agreement with the federal secretary of health and human services, as required by 42 USC 1396r-8, if the prescribing provider under sub. (1) demonstrates to the department’s satisfaction that no other drug sold by a manufacturer who complies with 42 USC 1396r-8 is medically appropriate and cost-effective in treating the recipient’s condition;

DHS 107.10(2)(f) (f) Drugs identified by the department that are sometimes used to enhance the prospects of fertility in males or females, when proposed to be used for treatment of a condition not related to fertility; and

DHS 107.10(2)(g) (g) Drugs identified by the department that are sometimes used to treat impotence, when proposed to be used for the treatment of a condition not related to impotence.

DHS 107.10 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.10(3) (3) Other limitations.

DHS 107.10(3)(a) (a) Dispensing of schedule III, IV and V drugs shall be limited to the original dispensing plus 5 refills, or 6 months from the date of the original prescription, whichever comes first.

DHS 107.10(3)(b) (b) Dispensing of non-scheduled drugs shall be limited to the original dispensing plus 11 refills, or 12 months from the date of the original prescription, whichever comes first.

DHS 107.10(3)(c) (c) Generically-written prescriptions for drugs listed in the federal food and drug administration approved drug products publication shall be filled with a generic drug included in that list. Prescription orders written for brand name drugs which have a lower cost commonly available generic drug equivalent shall be filled with the lower cost drug product equivalent, unless the prescribing provider under sub. (1) writes “brand medically necessary” on the face of the prescription.

DHS 107.10(3)(d) (d) Except as provided in par. (e), legend drugs shall be dispensed in the full amounts prescribed, not to exceed a 34-day supply.

DHS 107.10(3)(e) (e) The following drugs may be dispensed in amounts up to but not to exceed a 100-day supply, as prescribed by a physician:

DHS 107.10(3)(e)1. 1. Digoxin, digitoxin, digitalis;

DHS 107.10(3)(e)2. 2. Hydrochlorothiazide and chlorothiazide;

DHS 107.10(3)(e)3. 3. Prenatal vitamins;

DHS 107.10(3)(e)4. 4. Fluoride;

DHS 107.10(3)(e)5. 5. Levothyroxine, liothyronine and thyroid extract;

DHS 107.10(3)(e)6. 6. Phenobarbital;

DHS 107.10(3)(e)7. 7. Phenytoin; and

DHS 107.10(3)(e)8. 8. Oral contraceptives.

DHS 107.10(3)(f) (f) Provision of drugs and supplies to nursing home recipients shall comply with the department’s policy on ancillary costs in s. DHS 107.09 (4) (a).

DHS 107.10(3)(g) (g) Provision of special dietary supplements used for tube feeding or oral feeding of nursing home recipients shall be included in the nursing home daily rate pursuant to s. DHS 107.09 (2) (b).

DHS 107.10(3)(h) (h) To be included as a covered service, a non-legend drug shall be used in the treatment of a diagnosable medical condition and be a rational part of an accepted medical treatment plan. The following general categories of non-legend drugs are covered:

DHS 107.10(3)(h)1. 1. Antacids;

DHS 107.10(3)(h)2. 2. Analgesics;

DHS 107.10(3)(h)3. 3. Insulins;

DHS 107.10(3)(h)4. 4. Contraceptives;

DHS 107.10(3)(h)5. 5. Cough preparations;