SeniorCare: Covered Drugs

SeniorCare is a program for Wisconsin residents who are 65 or older and need help paying for medicine. The program helps seniors pay for prescription drugs and vaccines (PDF).

For more information, call SeniorCare Customer Service at 800-657-2038 or visit the SeniorCare home page.

You can also print this page.

What is covered

SeniorCare covers most prescription drugs and over-the-counter insulin. Most drugs are only covered for a 34-day supply, although some maintenance drugs may be covered for a 100-day supply.

• Brand-name prescription drugs.
• Generic prescription drugs.
• Over-the-counter insulin.

There are some exceptions to brand-name and generic prescription drugs the program covers.

You can also get certain vaccines with no out-of-pocket costs. Depending on other coverage you have in addition to SeniorCare, you may need to get some vaccines at a pharmacy and others at your doctor’s office. Check with your plan on where you can get vaccines. Learn how to get the vaccines you need (PDF).

Prior authorization

Some prescription drugs require approval from SeniorCare to be covered. This is called prior authorization.

Your pharmacist may have to get prior authorization for some prescription drugs. Vaccines do not need prior authorization.

If the drug isn’t approved, it won’t be covered by SeniorCare. The cost also won’t count toward your spenddown or deductible (the amounts you have to reach in SeniorCare before you can pay a copay for covered prescription drugs).

What is not covered

SeniorCare does not cover:

• Brand-name drugs unless they’re determined medically necessary by your doctor.
• Drugs from manufacturers that haven’t signed a rebate agreement with the state.
• Drugs that are experimental or have a cosmetic, not medical, purpose.
• Prescription drugs that are denied prior authorization.
• Over-the-counter medicines like vitamins and aspirin, even if prescribed. An exception is insulin.

Your pharmacy must let you know if a drug isn’t covered before filling your prescription. If you choose to buy a prescription drug that isn’t covered, you’ll have to pay the whole cost. It will not count toward your spenddown or deductible.

If your pharmacy tells you a drug isn’t covered, ask:

• Is it because it’s not covered by SeniorCare?
• Is it because the drug manufacturer didn’t sign a SeniorCare rebate agreement?
• Is it because you don’t have it available?

This will help you decide if you want to ask for an alternative drug or if SeniorCare won’t be able to cover it at all.

Out-of-state benefits

If you travel outside of Wisconsin for an extended period, you need to ask your pharmacy to send your covered prescription drugs to you.

SeniorCare won’t cover prescription drugs filled by pharmacies that are outside of Wisconsin and don’t participate in the program except in these circumstances:

• An emergency happens, either from an accident or illness, that requires covered prescription drugs. This must occur in the United States, Canada, or Mexico, and the pharmacy must fill out all the necessary forms.
  • Out-of-state pharmacies should call ForwardHealth Provider Services at 800-947-9627 to file a reimbursement claim.

  Participating pharmacies

  All pharmacies certified to serve Wisconsin Medicaid members are also certified to serve SeniorCare members. More than 95% of all pharmacies in the state participate in Wisconsin Medicaid.

  If you need help finding a participating pharmacy, call SeniorCare Customer Service at 800-657-2038.

  SeniorCare only covers services performed by a participating pharmacy. The pharmacy is responsible for submitting claims to the program. SeniorCare doesn’t pay members directly for services received. For that reason, you shouldn’t send bills or prescription receipts.

  Coverage limitations for SeniorCare participation levels 2B and 3

  Covered prescription drugs for members in participation levels 2B and 3 are limited to those whose manufacturer signed a rebate agreement with the state of Wisconsin. These agreements help fund the program because the manufacturer makes rebate payments to the state for drugs paid for by SeniorCare.

  If the manufacturer of the prescription drug you take hasn’t signed a rebate agreement, there may be an alternative drug available. Your pharmacist may be able to help you get a drug from a manufacturer that has signed an agreement.

  You can also call SeniorCare Customer Service at 800-657-2038 if you need help determining which drugs are covered by the program.

  More resources

  We are an equal opportunity employer and service provider. If you have a disability and need to access this information in a different format, or in another language, call 608-266-3356 or 888-701-1251 TTY. Translation services are free.

  If you have a civil rights question, call 608-267-4955, TTY: 711.