SeniorCare Prescription Drug Assistance
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SeniorCare covers most prescription drugs and over-the-counter insulin. Reimbursement for most drugs is limited to a 34-day supply. Some maintenance drugs may be provided in a 100-day supply.
SeniorCare "covered drugs" include:
- Generic prescription drugs.*
- Brand name prescription drugs.*
- Over-the-counter insulin.
*There are some restrictions to coverage of brand name and generic prescription drugs.
Some prescription drugs require prior approval from the SeniorCare Program before you get them in order for them to be covered by SeniorCare. This is called prior authorization.
Your pharmacist must obtain prior authorization before some categories of prescription drugs and prescription drugs that appear to be for cosmetic use only can be covered. If prior authorization is not approved, the drug(s) will not be reimbursed and expenditures for the drug will not be applied to your spenddown or deductible.
Prescriptions Not Covered
SeniorCare will not pay for:
- Prescription drugs administered in a physician’s office.
- Drugs that are experimental or have a cosmetic, not a medical, purpose.
- Over-the-counter drugs such as vitamins and aspirin even if prescribed, except for insulin.
- Prescription drugs for which prior authorization has been denied.
- Brand name drugs unless medically necessary, as determined by your physician.
- Drugs from manufacturers who have not signed a rebate agreement with the state.
The participating pharmacy provider must notify you of any prescription drug that is not covered before filling your prescription. If you choose to purchase a non-covered prescription, you will be responsible for the entire cost of the drug. In addition, any amount paid for a non-covered drug will not count toward your spenddown or deductible.
Out-of-State Prescription Benefits
If you are traveling outside of Wisconsin for an extended period, you will need to arrange with your local Wisconsin certified pharmacy to have prescriptions sent to you. SeniorCare will not cover prescription drugs provided by non-participating pharmacies while you are outside of Wisconsin except under the following circumstances:
- When you are within the United States, Canada, or Mexico, and an emergency arises from an accident or illness requiring covered prescription drugs and when the pharmacy completes all the necessary forms. (An out-of-state pharmacy, that is not a certified Wisconsin SeniorCare provider, should contact SeniorCare Provider Services at 1-800-947-9627 to file a claim for reimbursement.)
- When prior authorization has been granted for provision of a non-emergency prescription drug, and you are within the United States, Canada, or Mexico.
All pharmacies certified to serve patients in Wisconsin Medicaid are also certified to serve SeniorCare participants. Over 95% of all pharmacies in Wisconsin participate in Wisconsin Medicaid. For help in finding a participating pharmacy provider contact the SeniorCare Customer Service Hotline at 1-800-657-2038.
SeniorCare only covers services billed by participating pharmacies. Participating pharmacies are responsible for submitting claims directly to the SeniorCare Program. SeniorCare does not reimburse participants directly for covered services. Participants should not submit bills or receipts for prescriptions to the SeniorCare Program.
Coverage Limitations for SeniorCare Levels 2b and 3
Coverage of drugs for SeniorCare participants in Levels 2b and 3 is limited to drugs from manufacturers that enter into a SeniorCare rebate agreement with the State. By signing a SeniorCare rebate agreement, manufacturers agree to make rebate payments to the State for those prescription drugs which were paid for by SeniorCare. This will help fund the SeniorCare program.
If the manufacturer of the prescription drug that you take has not signed a SeniorCare rebate agreement there may be an alternative drug available. Your pharmacist may be able to help you find an alternative drug from a manufacturer that has signed an agreement. The SeniorCare Customer Service Hotline can help you determine which drugs are covered by SeniorCare.
Participating pharmacies know what limits are placed on prescription drugs by the SeniorCare Program. The provider must tell you if the SeniorCare Program does not cover a prescription drug before the drug is dispensed. If a prescription drug is not covered by the SeniorCare Program, a provider may charge you for those drug costs if the provider has informed you and received your consent prior to the purchase.
Questions to Ask
If your pharmacy tells you that a drug is "not covered" you should ask:
- Is it "not covered" because this is not a drug covered by SeniorCare?
- Is it "not covered" because the manufacturer did not sign a SeniorCare rebate agreement?
- Is it "not covered" because you do not have it available?
Asking these questions will help you decide whether or not you want to request an alternative drug or if SeniorCare will not be able to cover the drug at all.
For More Information:
- Call the SeniorCare Customer Service Hotline at 1-800-657-2038, or
- Visit the SeniorCare Web site at: dhs.wi.gov/seniorcare/index.htm.
DHS is an equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format, or need it translated to another language, please contact the SeniorCare Customer Service Hotline at 1-800-657-2038. All translation services are free of charge.
For civil rights questions call (608) 266-9371 or 1-888-701-1251 (TTY).