Pharmacy Coverage a. Pharmacy Coverage HMOs must carve out all SSA §1927 covered outpatient drugs to fee-for-service (covered outpatient drugs include drugs dispensed in a pharmacy, administered in a doctor’s office, or clinic; drugs reimbursed at bundled rate are not considered outpatient drugs). Per Article III, section C, the HMO must coordinate the services it provides to members with services a member receives through Medicaid Fee-for-Service.
Pharmacy Coverage a. Pharmacy Coverage Prescription, over-the-counter, diabetic and other drug related supplies (as defined by the Department), medication therapy management and provider administered drugs under Article IV, A.1.o, is carved out of the capitation rate for all BadgerCare Pus and/or Medicaid SSI members and will be paid on a fee-for-service basis. Per Article III, section C, the HMO must coordinate the services it provides to members with services a member receives through Medicaid Fee-for-Service.
Pharmacy Coverage a. Pharmacy Coverage Prescription, over-the-counter, diabetic and other drug related supplies (as defined by the Department), medication therapy management and provider administered drugs, under Article IV, A.1.j, is carved out of the nonrisk prepayment for the FCMH Program and will be paid on a fee-for-service basis.
Pharmacy Coverage. PIHPs must carve out all SSA §1927 covered outpatient drugs to fee-for- service (covered outpatient drugs include drugs dispensed in a pharmacy, administered in a doctor’s office, outpatient hospital or clinic; drugs reimbursed at bundled rate are not considered outpatient drugs).
Pharmacy Coverage l. Chiropractic services, unless the HMO elects to provide chiropractic services. Addendum V contains additional summary information on BadgerCare Plus and Medicaid SSI covered services. Please refer to the ForwardHealth Provider Updates for the most current information regarding BadgerCare Plus and/or Medicaid SSI covered services.
Pharmacy Coverage. 2. Medical Necessity The actual provision of any service is subject to the professional judgment of the HMO providers as to the medical necessity of the service, except that the HMO must provide assessment, evaluation, and treatment services ordered by a court. Decisions to provide or not to provide or authorize medical services shall be based solely on medical necessity and appropriateness as defined in HFS 101.03(96m). Disputes between the HMO and members about medical necessity can be appealed through the HMO grievance system, and ultimately to the Department for a binding determination; the Department’s determinations will be based on whether BadgerCare Plus and/or Medicaid SSI would have covered the service on a FFS basis (except for certain experimental procedures).
Pharmacy Coverage l. Chiropractic services, unless the HMO elects to provide chiropractic services.
Pharmacy Coverage a. Pharmacy Coverage Pharmacy coverage, including provider-administered drugs under Art. III, E, 3, is carved out of the capitation rate for all BadgerCare Plus and/or Medicaid SSI members and will be paid on a fee-for-service basis.
