The Pharmacy Drug Reimbursement Program is administered by the Tuberculosis Program of the Division of Public Health, Department of Health Services. The TB Program will directly reimburse pharmacies for covered medications for their eligible clients. Payment will be equal to or less than the Wisconsin Medicaid rate.
The Pharmacy Drug Reimbursement Program covers the following antituberculosis medications:
- isoniazid (INH)
- rifampin (Rifadin, Rimactane)
- rifapentine (Priftin®)
- pyrazinamide (PZA)
- ethambutol (Myambutol)
- Rifater and Rifamate® (combination)
The following second line antituberculosis drugs for drug-resistant tuberculosis are also covered:
- capreomycin (Capastat®)
- ciprofloxacin (Cipro®)
- clofazimine (Lamprene)
- cycloserine (Seromycin®)
- ethionamide (trecator-sc)
- gatifloxacin (Tequin®)
- kanamycin (Kantrex®)
- levofloxacin (Levaquin®)
- linezolid (Zyvox®)
- moxifloxacin (Avelox®)
- ofloxacin (Floxin®)
- parminosalicylic acid (PAS)
Under special circumstances, payment authorization is occasionally given for medications not listed above. Such authorization must be obtained in advance from one of the state TB nurse consultants.
Beginning in 2014, the following medications may also be covered:
- Anti-nausea prescription medications while taking TB medications.
- Vitamin B6 (pyridoxine) when INH is also prescribed, for pregnant women; breast-feeding infants; those with poor nutrition, diabetes, uremia, alcoholism, malnutrition, HIV, or seizure disorders; OR those with multi-drug-resistant TB.
- A multivitamin that contains vitamin D 400 IU (10 mcg) for infants 0-12 months, 600 IU (15 mcg) for children and adults.
- Nutritional supplement such as Ensure®.
An invoice should be completed by the pharmacist and signed by both the pharmacist and the customer or the patient's representative (signature can also be on signature log rather than on each invoice). Claims should be submitted monthly. Payments by the TB Program will be made directly to the pharmacy. See list of covered medications above.
The invoice must include the information indicated below or your claims may be returned for further information, resulting in a delay of your payment.
- Pharmacy name, street address, city, state, zip.
- Pharmacy FEIN (federal employer identification number). This is needed to ensure payment to the appropriate pharmacy.
- Client ID number. This is indicated on the antituberculosis therapy authorization form.
- Client name.
- Date each prescription is filled.
- Product name.
- Metric quantity and/or number of pills dispensed.
- Days of supply:
One month or a 30-day supply is the maximum amount dispensed to a patient at one time.
- National drug code (NDC) (labeler number, product number and package):
Include all of the digits of the NDC, including zeros. Claim forms with incomplete numbers may be rejected.
- Ingredient cost:
Enter your usual and customary price for the drug. Reimbursement is based upon the Wisconsin Medical Assistance Program (WMAP) allowable rate.
- Dispensing fee:
Enter current Medical Assistance (MA) professional fee.
The State of Wisconsin is exempt from paying state sales tax.
- Total price:
Ingredient cost plus dispensing fee.
- Signature of pharmacist or employee.
- Other third-party coverage:
WMAP also pays for all medications covered by the TBPDRP. WMAP must be billed first if the client has MA. If the pharmacy is aware that an individual has health insurance with prescription drug coverage, the pharmacy should bill insurance that portion for which the insurer is responsible. The TB Program should be billed only for the amount (copay and/or deductible) that the pharmacy has been authorized by the TBPDRP to bill. If you have benefit coordination questions, call TB Program Office Operations at 608-266-9692.
- Deductible amount:
Include the amount already paid per medication by the clients insurance or other source of medication coverage (e.g., Medicaid).
Indicate amount for which you are billing the TB Pharmacy Drug Reimbursement Program.
If the client is eligible for MA or the pharmacy is aware of other insurance coverage while enrolled in the Pharmacy Drug Reimbursement Program, the pharmacy must bill them first. The TBPDRP is the payer of last resort. As with the MA program, pharmacies may not bill clients for the difference between their usual and customary charges and the reimbursement rate they receive from the TBPDRP.
- Retain one copy of the completed invoice for your records.
- Send one copy in an envelope marked "confidential" to:
Pharmacy Drug Reimbursement Program
Wisconsin Division of Public Health
PO Box 2659
Madison, WI 53701-2659
For more information or questions, contact the Respiratory Diseases and International Health Unit or your Wisconsin Local Health Department.