|
 |
Wisconsin SeniorCare Fact Sheet
|
PDF (17 KB)
Covered Drugs
Covered Prescriptions
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.
Covered Drugs
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.
Prior Authorization
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.
Participating Pharmacies
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.
SeniorCare Rebate Agreement Effective Date
Drug manufacturers must sign SeniorCare rebate agreements by August 1, 2003
for their drugs to continue to be covered after September 1, 2003. If a
manufacturer signs a rebate agreement after August 1, 2003, their drugs will
again be considered "covered" the beginning of the next quarter of the year. For
example, if a manufacturer signs the rebate agreement on October 15, 2003, their
drugs will not be covered by SeniorCare until January 1, 2004.
For More Information:
- Call the SeniorCare Customer Service Hotline at (800) 657-2038, or
DHFS 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 (608) 266-3356
or (608) 266-2555 TTY. All translation services are free of charge.
For civil rights questions call (608) 266-3465 or (608)
266-2555 TTY.
PHC 10084 (07/03)
Learn
about PDF documents
Date Last Revised:
February 11, 2009
| 
