Policy

Same As Wisconsin Medicaid

Wisconsin Medicaid

Wisconsin SeniorCare

34 and 100 Days’ Supply

Yes

A 100 days’ supply is allowed for a limited number of drugs. All other drugs may be dispensed in a 34 days’ supply.

A 100 days’ supply is allowed for a limited number of drugs. All other drugs may be dispensed in a 34 days’ supply.

Provider Help Desk

Yes

(800) 947-9627
(608) 221-9883

(800) 947-9627
(608) 221-9883

Eligibility Verification

Yes

(800) 947-3544
(608) 221-4247

(800) 947-3544
(608) 221-4247

Patient Customer Service

No

(800) 362-3002
(608) 221-5720

(800) 657-2038

Claims Submission Methods

Yes

Refer to the Pharmacy Handbook for additional information on claims submission.

Refer to the Pharmacy Handbook for additional information on claims submission.

Prospective and Retrospective Drug Utilization Review (DUR)

Yes

Refer to the Drug Utilization Review and Pharmaceutical Care section of the Pharmacy Handbook for additional information.

Refer to the Drug Utilization Review and Pharmaceutical Care section of the Pharmacy Handbook for additional information.

Dispensing Fee

Yes

The dispensing fee is $4.88.

The dispensing fee is $4.88.

Covered Drugs

No

Legend drugs and over-the-counter insulin with a signed manufacturer rebate agreement are covered.

Brand Medically Necessary

No

SeniorCare will not cover a brand medically necessary drug unless the prescription order indicates "brand medically necessary" in the prescriber’s own handwriting.

Compound Dispensing

Yes

Brand Medically Necessary Prior Authorization (PA)

No

Effective for dates of service (DOS) on and after September 1, 2004, Wisconsin Medicaid requires PA for brand medically necessary drugs.

Effective for DOS on and after September 1, 2004, Wisconsin SeniorCare requires PA for brand medically necessary drugs. Drugs without a manufacturer rebate agreement are not covered and cannot be obtained even with a PA request.

Prior Authorization

No

Drugs without a manufacturer rebate agreement may be covered with a PA request. Refer to Attachments 1, 4, and 5 of this Wisconsin Medicaid and BadgerCare Update for drug classes that require PA.

Drugs without a manufacturer rebate agreement are not covered and cannot be obtained even with a PA request. Refer to Attachments 1, 4, and 5 for drug classes that require PA.

Pharmaceutical Care (PC)

No

Pharmaceutical Care services may be billed through real-time pharmacy Point-of-Sale (POS) system or by using the Noncompound Drug Claim form. Indicate PC codes in the three fields shared with DUR and the level of effort field. Wisconsin Medicaid reminds providers that limitations exist on PC billing and reimbursement.

Pharmaceutical care services may be billed through the real-time pharmacy POS system or by using the Noncompound Drug Claim form. Indicate PC codes in the three fields shared with DUR and the level of effort field. As a reminder, limitations exist on PC billing and reimbursement. Providers must have a participant's prior consent to receive and be charged for PC services. SeniorCare will reimburse PC services during the copayment period.

Copayment

No

• $0.50 for over-the-counter drugs.
• $1.00 for each generic prescription drug, generic insulin, and each compounded drug.
• $3.00 for each brand name prescription drug and insulin.

There is a $12.00 per month per pharmacy per recipient limit. Over-the-counter drugs are not included in this maximum out of pocket requirement.

• $5 for each generic prescription drug, generic insulin, and each compounded drug.
• $15 for each brand name prescription drug and insulin.
• Over-the-counter drugs, except for insulin, are not covered.

Copayment Exemptions

No

The following copayment exemptions apply to Wisconsin Medicaid recipients:

• Emergency services.
• Family planning and related supplies.
• Pharmaceutical Care dispensing fee.
• Services supplied to nursing facility residents.
• Services provided to recipients under 18 years of age.
• Services provided to pregnant women if the services are pregnancy related.
• Services provided to enrollees of a Medicaid HMO or special managed care plan.

There are no copayment exemptions for Wisconsin SeniorCare participants.

Drug Reimbursement Rate

No

Wisconsin Medicaid reimbursement is currently Average Wholesale Price (AWP) minus 13 percent plus dispensing fee or Maximum Allowable Cost.

• Level 1 (copayment) — Wisconsin SeniorCare reimburses pharmacies up to the SeniorCare rate (i.e., Medicaid ingredient rate plus 5 percent, plus the Medicaid dispensing fee).
• Levels 2a & 2b (deductibles) — participant pays up to the SeniorCare rate.
• Level 3 (spenddown) — participant pays up to retail price.

Remittance and Status (R/S) Report

Yes

Medicaid and SeniorCare claims will appear on the same weekly R/S Report or the Health Care Claim Payment/Advice 835.

Medicaid and SeniorCare claims will appear on the same weekly R/S Report or the Health Care Claim Payment/Advice 835.

Identification Cards

No

Forward card

SeniorCare card

Age Restriction

No

Some age restrictions depending upon the drug.

Some age restrictions depending on the drug. Participants must be 65 years of age or older to enroll in SeniorCare.

Managed Care

No

Medicaid recipients may be enrolled in Medicaid Managed Care programs.

SeniorCare participants will not be enrolled in Medicaid managed care programs.

Coordination of Benefits

No

Pharmacies are required to submit other insurance payment information or the appropriate disclaimer when submitting claims to Wisconsin Medicaid.

Pharmacies are required to submit any out-of-pocket expenses the participant incurs in the "Patient Paid Amount" field and any other insurance payments, or the appropriate disclaimer, in the "Other Payor Amount" field.