Drug Coverage Under the BadgerCare Plus Benchmark Plan

Covered Drugs

The BadgerCare Plus Benchmark Plan only covers drugs listed on the Benchmark Plan formulary, which includes certain generic drugs and a limited number of over-the-counter drugs. The Benchmark Plan formulary is published as the BadgerCare Plus Benchmark NDC (National Drug Code) List in the Pharmacy Data Tables section of the Wisconsin Medicaid Web site at dhfs.wisconsin.gov/medicaid4/pharmacy/data_tables/index.htm. This list may be updated monthly so providers should check the Web site often for changes to the BadgerCare Plus Benchmark NDC List.

Noncovered Drugs

The Benchmark Plan does not cover any brand name drugs or those generic drugs that are not included on the Benchmark Plan formulary. Prior authorization (PA) is not available for drugs that are not included on the Benchmark Plan formulary. Prior authorization requests submitted for noncovered drugs will be returned to the provider. Benchmark Plan members do not have appeal rights regarding returned PA requests for noncovered drugs.

Drug Coverage Under the BadgerRx Gold Program

Covered Drugs and Resources

Drugs that are not covered by the Benchmark Plan may be available to Benchmark Plan members through the BadgerRx Gold Program. The BadgerRx Gold Program is a prescription drug program administered by Navitus Health Solutions that offers certain drugs at a lower cost. All Benchmark Plan members are automatically enrolled in the BadgerRx Gold Program.

The formulary for the BadgerRx Gold Program is available through the BadgerRx Gold Web site at www.badgerrxgold.com/badgerrxgold/default.asp. Additional questions may be directed to the toll-free BadgerRx Gold hotline at (866) 809‑9382.

The BadgerRx Gold Program provides members with select drugs at a lower cost; however, the cost of a drug covered by the BadgerRx Gold Program may be greater than a typical copayment amount under the Benchmark Plan. Members will have a greater financial responsibility for drugs purchased through the BadgerRx Gold Program.

Noncovered Drugs

Members are responsible for the full price of drugs that are not covered by the BadgerRx Gold Program or the Benchmark Plan.

Options for Obtaining Necessary Drugs for Members

Members who are currently enrolled in the Benchmark Plan may need drugs that were previously covered under the Wisconsin Medicaid program but are not covered under the Benchmark Plan. In some cases, the cost of noncovered drugs may be too high for members to afford. If possible, prescribers should consider switching the member to a generic drug that is covered under the Benchmark Plan. Pharmacies are reminded that a copayment of up to $5.00 applies to all Benchmark Plan prescriptions; pregnant women and members 18 years of age or younger who are tribal members are exempt from the copayment requirement.

Pharmacies may receive a pharmaceutical care dispensing fee for working with prescribers to find generic equivalents for Benchmark Plan members.

There are several other options available for Benchmark Plan members whose drug coverage has changed. Providers can help members in the following ways:

• Urge members to verify enrollment and eligibility for assistance programs using the following methods:
  • Double-check enrollment with the local county/tribal office.
  • Use the Access online tool (available at https://access.wisconsin.gov/) to determine possible eligibility for other state assistance programs.
• Offer members information about prescriptions and drug costs.
  • Check if a prescribed drug is included in the BadgerRx Gold formulary and explain the greater financial responsibility to the member.
  • Dispense a smaller quantity of a drug if a member needs it immediately but cannot afford a full prescription.
• Refer members to Member Services at (800) 362-3002 with questions and concerns about drug coverage.