Wisconsin Medicaid, BadgerCare, and SeniorCare do not cover the following drugs.

Note: This table includes Wisconsin Medicaid’s most current information and may be updated periodically. Certain drugs listed in these tables are registered or trademarked by the manufacturer.

Noncovered Drugs

Alginate

Eflornithine (Vaniqa) Topical

Finasteride (Propecia)

Gaviscon

Less-than effective drugs

Minoxidil Topical

Drugs without signed manufacturer rebate agreements*

Progesterone for premenstrual syndrome (PMS)

Legend Multivitamins (nonprenatal) — excludes HealthCheck

*Wisconsin SeniorCare will not cover prescription drugs, even with a prior authorization (PA) request, that do not have a signed rebate agreement between the Department of Health and Family Services and the manufacturer; however, these drugs may be covered for Wisconsin Medicaid recipients if a paper PA request is submitted to Wisconsin Medicaid.

Noncovered Fertility Enhancement Drugs (When Used to Treat Infertility)

Chorionic Gonadotropin

Clomiphene

Crinone

Gonadorelin

Menotropins

Urofollitropin

Noncovered Impotence Treatment Drugs

Alprostadil Intracavernosal (Caverject, Edex)

Phentolamine Intracavernosal (Regitine)

Tadalafil (Cialis)

Sildenafil (Viagra)

Urethral suppository (Muse)

Vardenafil (Levitra)

Yohimbine

Attachment 1: Brand Medically Necessary Drugs That Require Prior Authorization
Attachment 2: Brand Medically Necessary Prior Authorization Documentation
Attachment 3: MedWatch Reporting Form (FDA Web site) (PDF, 53 KB)
Attachment 4: Specialized Transmission Approval Technology-Prior Authorization (STAT-PA) Drugs
Attachment 5: Drug Products Requiring Paper Prior Authorization
Attachment 6: Diagnosis-Restricted Drugs (Organized by Generic Drug Name)
Attachment 7: Diagnosis-Restricted Drugs (Organized by Diagnosis Code Description)
Attachment 8: Covered Over-the-Counter Drugs
Attachment 10: Age- and Gender-Restricted Drugs
Attachment 11: Covered Over-the-Counter Drugs for HealthCheck "Other Services"
Attachment 12: Comparison of Wisconsin Medicaid and Wisconsin SeniorCare Policies
Attachment 13: Obsolete 1/1/05: STAT-PA Drug Worksheet for Brand Name Clozaril^® (fillable PDF, 236 KB) — Use Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) (fillable PDF, 225 KB)  | Instructions (PDF, 71 KB)

Back to the beginning of this Update