Medicaid-Approved Preferred Drug List (PDL) — Coverage Criteria
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Wisconsin policy alerts
Know when Blue Cross Blue Shield - Wisconsin releases new policies or updates existing guidance.
Monitor payer policy activity
A listing of prescription and OTC medications with coverage annotations (e.g., PA, QL, AL, DO, SP, ST) applicable to Medicaid members in Wisconsin; intended for prescribers, pharmacies, and utilization management staff.
No material clinical or coverage changes in this revision.
Coverage Criteria and Product Listings
Annotated Requirements (PA, QL, AL, DO, SP, ST)
Coverage is indicated per drug entry by annotations. Coverage and access depend on meeting the annotation requirements below.
Examples include many specialty biologics and selected stimulants
QL appears across inhalers, injectables, tablets, OTC items and supplies
AL annotations appear for selected contraceptives, topical and other products
DO appears adjacent to certain formulations (see listing)
Examples include many biologic agents and some antiretrovirals
ST presence is indicated in the PDL; specific sequences are defined in the payer's step therapy rules
Prescribers should supply required documentation (e.g., indicate 'OTC' on prescriptions for OTC items when covered)
Listed products with coverage flags
Coverage listing and notes
Entries are product lines; no explicit medical necessity criteria provided in these chunks.
This document is a formulary-style Preferred Drug List (PDL) that organizes medications by therapeutic class and indicates coverage annotations alongside each product. The extract does not contain standalone exclusion statements; instead, coverage implications are conveyed through the listing and the shorthand notes in the legend (for example, PA, QL, AL, DO, SP, ST).
The provided legend excerpt does not state discrete clinical coverage criteria or explicit exclusions — it presents product lines with attached utilization annotations. Coverage and administrative requirements are implied by those annotations rather than by separate criteria text; for example, entries show OTC and QL next to many products and the legend defines the shorthand used.
Within this excerpt coverage is expressed only via the formulary shorthand notes. The extract includes items annotated with PA (prior authorization), SP (specialty pharmacy), QL (quantity limits), AL (age/access limits) and DO (dose/dispense designation). No further clinical rule text or step sequences are provided in these chunks.
No explicit exclusions are stated in the partial extract. The listing approach implies coverage is limited to items shown under the PDL headings and subject to any annotations; absence of a product from the extraction does not by itself constitute an exclusion statement in the provided text.
This partial extract does not include additional coverage-criteria sections beyond the formulary listings and legend definitions shown. No separate coverage decision logic or clinical-necessity rules are present in these chunks.
The supplied extract does not contain further coverage-criteria content for other classes beyond the product listings and notes in the fragments provided. Additional criteria may exist in the full PDL but are not present in this partial extract.
Drug/Product Coding and Identifiers
| HADLIMA | HADLIMA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE |
| HADLIMA PUSHTOUCH | HADLIMA PUSHTOUCH SUBCUTANEOUS SOLUTION AUTO- INJECTOR |
| HADLIMA (prefilled) | adalimumab-bwwd subcutaneous solution prefilled syringe |
| ADALIMUMAB-BWWD | adalimumab-bwwd subcutaneous solution auto-injector |
| AMJEVITA | AMJEVITA SUBCUTANEOUS SOLUTION AUTO-INJECTOR |
| AMJEVITA (prefilled) | AMJEVITA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE |
| AMJEVITA-PED 10KG-<15KG | AMJEVITA-PED 10KG TO <15KG SUBCUTANEOUS SOLUTION PREFILLED |
| AMJEVITA-PED 15KG-<30KG | AMJEVITA-PED 15KG TO <30KG SUBCUTANEOUS SOLUTION PREFILLED |
| SIMLANDI (1 PEN) | SIMLANDI (1 PEN) SUBCUTANEOUS AUTO-INJECTOR KIT |
| SIMLANDI (2 PEN) | SIMLANDI (2 PEN) SUBCUTANEOUS AUTO-INJECTOR KIT |
| No codes listed |
Provider Actions — Prior Authorization, Step Therapy, Documentation
Obtain prior authorization for PA‑flagged products
Certain products listed with the note 'PA' require prior authorization before benefits are approved; providers must obtain PA per the PDL before dispensing these products.
- PA flag indicates prior authorization is required.
PA required for XOLAIR formulations
XOLAIR formulations are annotated 'PA' (and often 'SP; QL'); prior authorization must be obtained before coverage is approved for any XOLAIR presentation.
- XOLAIR subcutaneous solution auto‑injector, prefilled syringe, and reconstituted forms are noted PA; SP; QL.
PA required for listed antineoplastics and select agents
Selected agents in the antineoplastic and antibiotic listings (e.g., linezolid; imatinib; gefitinib) are annotated 'PA' (and often 'SP; QL'); prior authorization must be obtained for these agents.
- Imatinib mesylate: Notes = PA; SP; QL.
- Gefitinib: Notes = PA; SP; QL.
- Linezolid and other agents in these sections include PA/QL annotations.
Obtain PA for specified LAI antipsychotics
Long‑acting injectable antipsychotics such as INVEGA SUSTENNA, INVEGA TRINZA, ABILIFY MAINTENA and ARISTADA are annotated 'PA' and require prior authorization prior to coverage.
- INVEGA SUSTENNA and INVEGA TRINZA are listed with Notes = PA (and AL/QL where shown).
- ABILIFY MAINTENA / ARISTADA entries in the LAI antipsychotic section are PA‑flagged.
PA required for select antivirals/antiretrovirals
Select antiretroviral/antiviral agents (for example, BIKTARVY, TROGARZO, SUNLENCA) are annotated with PA (and often SP/QL); providers must submit prior authorization requests for these products.
- BIKTARVY: Notes = SP; QL (PA may apply per adjacent notes).
- TROGARZO: Notes = PA; SP; QL.
PA required for listed antiviral/hepatitis agents
Several antiviral and hepatitis agents (e.g., VIREAD/tenofovir DF, MAVYRET, sofosbuvir‑velpatasvir) are annotated 'PA' (often with SP and QL); prior authorization is required before coverage.
- VIREAD (tenofovir df): Notes = PA; SP; QL.
- MAVYRET and sofosbuvir‑velpatasvir: Notes = PA; SP; QL.
OTC/AL annotations present — PA not always specified
Some products in the listing are annotated OTC or AL without an explicit PA requirement in this excerpt; providers should follow the prescription and coverage labeling (e.g., indicate 'OTC' on prescriptions when applicable).
- OTC designation means over‑the‑counter product available with a prescription; prescribers should indicate 'OTC' on the prescription.
PA required for select decongestant/antihistamine products
Decongestant/antihistamine products such as CLARITIN‑D, ALLEGRA‑D and ZYRTEC‑D are annotated 'PA' (and/or AL; OTC; QL) in the listing; prior authorization is required for these PA‑flagged products.
- CLARITIN‑D entries: Notes = PA; AL; OTC; QL.
- ALLEGRA and ZYRTEC product lines include OTC/PA/QL annotations depending on formulation.
PA required for specified topical agents
Certain topical agents are annotated 'PA' (e.g., TRIDERM external cream; some ciclopirox products); prior authorization must be obtained per the PDL for these topical formulations.
- TRIDERM external cream: Notes = PA; QL.
- Ciclopirox external solution/cream: Notes = PA; QL.
PA required for listed topical and diagnostic items
Specific listed items are annotated 'PA' (e.g., podofilox external solution; lidocaine external patch 5%; TRUE METRIX test strips); obtain prior authorization before coverage to avoid denial.
- Podofilox external solution: Notes = PA; QL.
- Lidocaine external patches and certain strengths: Notes include OTC; QL and some PA annotations.
- TRUE METRIX blood glucose test strips: Notes = PA; OTC; QL.
PA required for specified CGM and insulin delivery devices
Continuous glucose monitoring (CGM) components and certain insulin delivery system kits/pods (e.g., DEXCOM G6/G7, FreeStyle Libre series, OMNIPOD kits/pods) are annotated 'PA' (and QL); prior authorization is required for these devices.
- DEXCOM G6/G7 sensors, transmitters, receivers: Notes = PA; QL.
- FREESTYLE LIBRE sensors/readers (various generations): Notes = PA; QL.
- OMNIPOD DASH kits/pods: Notes = PA; QL.
Follow step therapy when 'ST' is indicated
Drugs annotated 'ST' on the PDL require step therapy — a specified medication must be tried first before alternatives are authorized; providers must follow step therapy requirements when submitting PA/coverage requests.
- ST flag indicates step therapy is required prior to authorization of alternate agents.
Specialty‑designated products (SP) — route and step implications
Products marked 'SP' indicate specialty pharmacy designation and may have specialty or step implications; providers should route prescriptions through specialty channels and follow any specialty/step procedures required by the payer.
- SP flag denotes specialty pharmacy handling; may require PA and QL as shown next to many specialty agents.
Utilization controls for specialty/high‑cost classes
High‑cost specialty classes (for example, PCSK9 inhibitors and some antineoplastics) are annotated with utilization controls (e.g., 'PA; QL; SP'); these annotations imply prior authorization, specialty handling, and potential step or quantity controls before coverage.
- PA; QL; SP annotations together indicate multiple utilization management controls that may include step requirements elsewhere in the full PDL.
SP/QL flags present — no step sequences shown in excerpt
The PDL excerpt includes 'SP' and 'QL' flags for many products but does not specify explicit step therapy sequences in this excerpt; providers must consult the full PDL or PA criteria for detailed step rules.
- Presence of SP/QL flags signals potential step or quantity controls but no step sequence is provided here.
SP/AL annotations present — alternatives not specified here
Listings include 'SP' and 'AL' annotations for certain products (specialty or access/age limits) without explicit multi‑step sequences in this excerpt; follow payer guidance for any required alternatives or routing.
- AL and SP flags may indicate age/access limits or specialty routing; check full policy for required sequences or alternatives.
No step therapy sequences specified in excerpt
No explicit step therapy sequences are provided in these chunks of the PDL excerpt; where step therapy applies, detailed sequences and prior medications to try first must be confirmed in the full PDL or PA criteria.
- Excerpt shows presence/absence of flags only; consult full policy for sequences.
SELARSDI and similar specialty agents require SP and PA handling
Some systemic or specialty products (for example, SELARSDI) are annotated 'SP' (and 'PA; QL'); these specialty‑flagged agents may be subject to specialty program routing and prior authorization requirements.
- SELARSDI: Notes = PA; SP; QL — prior authorization and specialty pharmacy handling expected.
Inventory item present — no summary provided
This inventory item is present in the listing but no summary details are provided in the excerpt; follow the PDL entries and PA processes for any action required.
No explicit step therapy sequences in these chunks
No explicit step therapy sequences are provided in these chunks; providers should not assume the existence of a specific step algorithm from the excerpt and must check full program rules when ST or SP flags appear.
Inventory item present — details not provided
This inventory item is present in the listing but no summary details are provided in the excerpt; consult the full PDL for any authorization or routing requirements.
Indicate 'OTC' on prescriptions for covered OTC items
For covered OTC products listed on the PDL, prescribers should indicate 'OTC' on the prescription to ensure correct processing under the plan's coverage rules.
- OTC notation on prescriptions is required for OTC products covered with a prescription.
Provide documentation per PA/QL/SP notes when required
Listings include utilization notes (PA, SP, QL, DO, OTC) adjacent to products; providers must supply documentation as required by prior authorization and quantity‑limit processes when submitting PA or claims.
- Provide medical necessity, prior therapy, dosage, and any specialty routing documentation as requested in PA processes.
Include clinical documentation for PA/QL/SP agents (e.g., imatinib, gefitinib)
Entries for selected agents (for example, linezolid, imatinib, gefitinib) include 'PA; QL' and/or 'SP' notes; when submitting PA requests for these agents, include supporting clinical documentation consistent with PA and specialty pharmacy requirements.
- Include diagnosis, prior treatments, dosing, and rationale for use to support PA and quantity‑limit requests.
Respond to PDL shorthand flags with required administrative documentation
The PDL uses shorthand flags (PA, SP, QL, AL, DO); when these annotations appear next to a product, providers must follow the payer's administrative processes (PA submission, specialty routing, quantity‑limit documentation) to secure coverage.
- PA = Prior authorization required; SP = Specialty Pharmacy; QL = Quantity limit; AL = Age/Access limit; DO = Dispense/other dispensing note.
Submit standard PA/QL documentation when annotations appear
PA or QL annotations adjacent to products indicate administrative controls; providers should follow standard PA and quantity‑limit documentation procedures per the payer when requesting coverage.
- For PA requests, include clinical justification and any required prior therapy documentation.
- For QL requests, document clinical need for quantities outside standard limits.
PA and QL documentation required for TRIDERM
The PDL entry for TRIDERM external cream is annotated 'PA; QL'; providers must submit PA requests and supporting documentation for coverage of TRIDERM and be prepared to meet any quantity‑limit controls.
- TRIDERM: Notes = PA; QL — PA and quantity‑limit documentation expected.
Provide PA and AL/QL documentation for topical immunomodulators
Topical immunomodulators pimecrolimus and tacrolimus are annotated 'PA; AL; QL'; prior authorization and any age/access limit documentation must be submitted to support coverage.
- Pimecrolimus external cream: Notes = PA; AL; QL.
- Tacrolimus external ointment: Notes = PA; AL; QL.
PA and quantity documentation required for Omnipod products
Omnipod kits and pods are annotated 'PA; QL'; prior authorization and documentation supporting medical necessity and requested quantities should be provided when seeking coverage.
- OMNIPOD DASH kits/pods: Notes = PA; QL — include medical justification and quantity details in PA requests.
Risk of denial if PA is not obtained for PA‑flagged drugs
Prescriptions for drugs marked 'PA' require prior authorization before benefits are approved; failure to obtain PA may result in claim denial or non‑coverage.
- Obtain PA prior to dispensing PA‑flagged medications to avoid denial.
Noncompliance with PA/SP/QL flags may trigger denial
Products annotated with 'PA', 'SP', or 'QL' indicate utilization restrictions; if PA/SP routing or quantity limits are not met, coverage may be denied.
- Ensure specialty routing and quantity limits are adhered to when those flags appear to prevent denial.
PA/SP/AL flags can trigger utilization denials
Entries with PA, SP, or AL flags represent utilization controls that can trigger denial if required authorizations, specialty processes, or age/access limitations are not satisfied.
- Confirm member eligibility, age limits, and obtain PA/Specialty approvals as indicated on the PDL.
PA/SP/QL for antineoplastic and antiviral products — denial risk if unmet
Requests for listed antineoplastic and antiviral products often have PA, SP and QL annotations; failure to secure required PA or specialty handling may result in denial of coverage.
- Imatinib and gefitinib (antineoplastics) and MAVYRET/sofosbuvir‑velpatasvir (antivirals) include PA/SP/QL — obtain required approvals.
Verify PA flags to avoid claim denial
Items explicitly marked 'PA' in the listing indicate prior authorization is required; absence of PA for these items on claim submission may lead to denial.
- Verify PA requirements for each product before dispensing or submitting claims.
Check full PDL where PA not explicitly shown
Some listing segments include only QL/AL/OTC notes without explicit PA triggers in the excerpt; nevertheless, providers should check full PDL guidance to confirm whether PA applies for individual formulations.
PA/QL flags may lead to denial if conditions unmet
Products labeled 'PA' or 'QL' may trigger denial if authorization or quantity‑limit requirements are not met; obtain PA and adhere to QL limits when requested to prevent coverage denial.
- Authorization or quantity‑limit denials are possible for PA/QL‑flagged products.
Combined PA/SP/QL annotations increase denial risk if unmet
Some products (for example, SELARSDI) are annotated 'PA; SP; QL', indicating combined prior authorization and specialty pharmacy requirements; claims submitted without meeting these requirements risk denial.
- SELARSDI entries: Notes = PA; SP; QL — follow specialty PA processes.
PA‑marked topical/diagnostic products may be denied without PA
Products marked 'PA' in the topical and diagnostics sections (e.g., podofilox, certain lidocaine patches, TRUE METRIX strips) may be denied if PA is not obtained; obtain PA to secure coverage.
- Podofilox: Notes = PA; QL.
- TRUE METRIX strips: Notes = PA; OTC; QL.
PA required for CGM devices — denial risk without PA
Claims for CGM devices and components (DEXCOM G6/G7, FREESTYLE LIBRE) marked 'PA' may be denied if prior authorization is not obtained; submit PA per payer requirements for device coverage.
- DEXCOM and FREESTYLE LIBRE sensor/reader entries: Notes = PA; QL — PA required for coverage.
PA/SP/QL apply to listed adalimumab biosimilars
Hadlima and Amjevita (adalimumab biosimilars) are listed with Notes = PA; SP; QL; providers must follow specialty pharmacy and prior authorization processes for these biologic products.
- Hadlima entries: Notes = PA; SP; QL.
- AMJEVITA entries: Notes = PA; SP; QL.
Background and Scope
This document is a Medicaid-Approved Preferred Drug List that organizes medications alphabetically by therapeutic class and annotates each entry with utilization controls. The legend defines shorthand used throughout the PDL — for example, PA (prior authorization required), QL (quantity limits), SP (specialty pharmacy), AL (age limits), DO (dose/dispense designation), ST (step therapy) and OTC (over-the-counter). Those annotations are the mechanism by which coverage conditions and administrative requirements are communicated to prescribers, pharmacies, and utilization management staff.
Abbreviations and Definitions
Step Therapy and Specialty Routing
| Item | Step therapy note |
|---|---|
| Drugs annotated 'ST' (step therapy) | |
| Step therapy requires that a specified medication be tried first before alternatives are authorized (ST = Step therapy is required) |
| Product / Class | Note |
|---|---|
| Anti‑IgE monoclonal antibodies (e.g., XOLAIR formulations) | |
| Marked 'SP' indicating specialty pharmacy handling; may imply specialty program or step requirements as noted in the formulary (PA; SP; QL present for XOLAIR) |
| Example products / classes | Annotations |
|---|---|
| High‑cost specialty classes (e.g., PCSK9 inhibitors; selected antineoplastics such as imatinib, gefitinib) | |
| Annotated 'PA; QL; SP' indicating prior authorization, quantity limits, and specialty management may apply before coverage |
| Observation | Details |
|---|---|
| Step therapy presence noted | |
| Some products include 'SP' and 'QL' notes suggesting step therapy may exist, but explicit step sequences or required first‑line agents are not provided in this excerpt |
| Agents | Implication |
|---|---|
| Antiretrovirals and select antivirals (e.g., PREZISTA, EDURANT) and other specialty agents | |
| Designated 'PA' or 'SP' indicating prior authorization and/or specialty pharmacy routing may be required prior to coverage |
| Finding | Consequence |
|---|---|
| No step therapy sequences specified in this excerpt | |
| Entries shown are formulary listings with annotations (AL; QL) but no explicit ST rules in these chunks |
| Product | Annotations |
|---|---|
| SELARSDI (subcutaneous solution; prefilled syringe) | |
| Annotated 'PA; SP; QL' indicating prior authorization, specialty pharmacy handling, and quantity limits |
| Item | Management pathway |
|---|---|
| SELARSDI and certain biologics | |
| Managed under specialty and prior authorization pathways before coverage (entries show 'PA; SP; QL') |
| Summary | Evidence in excerpt |
|---|---|
| No explicit step therapy requirements detailed | |
| Chunks show PA/QL flags for products such as podofilox and lidocaine patches but do not specify ST sequences in this segment |
| Device / Product | Access requirement |
|---|---|
| Dexcom G6/G7 components; FreeStyle Libre sensors/readers; selected Omnipod kits | |
| Annotated 'PA' (prior authorization) for specified continuous glucose monitoring sensors, receivers and select insulin delivery system kits/pods prior to coverage |
Quantity Limits and Supply Restrictions
Biosimilars and Reference Biologics
Policy Revision History
PDL became effective May 1, 2026 for Medicaid members (Medicaid‑Approved Preferred Drug List).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.