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;
DHS 107.10(3)(h)6.6. Ophthalmic lubricants; and
DHS 107.10(3)(h)7.7. Iron supplements for pregnant women.
DHS 107.10(3)(h)8.8. Non-legend drugs not within one of the categories described under subds. 1. to 7. that previously had legend drug status and that the department has determined to be cost effective in treating the condition for which the drugs are prescribed.
DHS 107.10(3)(i)(i) Any innovator multiple–source drug is a covered service only if the prescribing provider under sub. (1) certifies by writing the phrase “brand medically necessary” on the prescription to the pharmacist that the innovator brand drug, rather than a generic drug, is medically necessary. The prescribing provider shall document in the patient’s record the reason why the innovator brand drug is medically necessary. The innovators of multiple source drug are identified in the Wisconsin medicaid drug index.
DHS 107.10(3)(j)(j) A drug produced by a manufacturer who does not meet the requirements of 42 USC 1396r-8 may be a covered service if the department determines that the drug is medically necessary and cost-effective in treating the condition for which it is prescribed.
DHS 107.10(3)(k)(k) The department may determine whether or not a drug judged by the U.S. food and drug administration to be “less than effective”shall be reimbursed under the program based on the medical appropriateness and cost-effectiveness of the drug.
DHS 107.10(3)(L)(L) Services, including drugs, directly related to non-surgical abortions shall comply with s. 20.927, Stats., may only be prescribed by a physician, and shall comply with MA policy and procedures as described in MA provider handbooks and bulletins.
DHS 107.10(4)(4)Non-covered services. The department may create a list of drugs or drug categories to be excluded from coverage, known as the medicaid negative drug list. These non-covered drugs may include drugs determined “less than effective” by the U.S. food and drug administration, drugs not covered by 42 USC 1396r-8, drugs restricted under 42 USC 1396r-8 (d) (2) and experimental or other drugs which have no medically accepted indications. In addition, the following are not covered services:
DHS 107.10(4)(a)(a) Claims of a pharmacy provider for reimbursement for drugs and medical supplies included in the daily rate for nursing home recipients;
DHS 107.10(4)(b)(b) Refills of schedule II drugs;
DHS 107.10(4)(c)(c) Refills beyond the limitations imposed under sub. (3) (a) and (b);
DHS 107.10(4)(d)(d) Personal care items such as non-therapeutic bath oils;
DHS 107.10(4)(e)(e) Cosmetics such as non-therapeutic skin lotions and sun screens;