2. SeniorCare Prescription drug coverage for Wisconsin residents age 65+
Utilizes rebates with drug manufacturers
1,200 participating pharmacies within the state
DHS website:

3. SrCare Waiver Renewal SeniorCare operates on a waiver approved by CMS
The waiver is effective through December 31, 2028.

4. Basic requirements $30 annual fee Must be 65 years+ No asset test
No income limit
4 different benefit levels
Renew annually
No SEP necessary—enroll anytime!

5. SeniorCare Creditable coverage (avoids Part D penalty)
Alternative or a supplementary to Medicare Part D
Help with copays, coinsurance, deductibles, or to cover otherwise uncovered drugs
Online formulary available at Forward Health’s website:

6. How Does Gross Annual Income Determine Benefit Level?
SeniorCare will place an applicant in a benefit level depending on the amount of their gross annual income.
Levels are 1, 2a, 2b, and 3

7. SeniorCare Level 1 No deductible
Income at or below 160% FPL:
$19,984 per individual (under $1,665.33/month)
$27,056 per couple (under $2,254.67/month)
No deductible
Pay $5 and $15 for generic and brand name drugs

8. SeniorCare Level 2a $500 deductible
Income between 160% to 200% of the FPL:
$24,980 per individual ($2,081.67/month)
$33,820 per couple ($2,818.33/month)
$500 deductible
During the deductible period, the participant pays discounted SeniorCare rate on most covered drugs.
After meeting the deductible: $5 copay on generics and $15 copay on brand name prescriptions.

9. SeniorCare Level 2b $850 deductible
Income between % FPL
$29,976 per individual ($2,498/month)
$40,584 per couple ($3,382/month)
$850 deductible
During the deductible period, the participant pays discounted SeniorCare rate on most covered drugs.
After deductible: $5 copay on generics; $15 on brand name prescriptions.

10. SeniorCare Level 3 Both a spend-down and a $850 deductible
Income above 240% FPL
Above $29,977 for individuals ($2,498.08/month)
Above $40,585 for couples ($3,382.08/month)
Both a spend-down and a $850 deductible
Pay retail price during spend-down.
Pay SeniorCare rate during deductible.

11. What is a Spend-Down?
The amount of the spend-down is equal to the difference between a participant’s gross annual income and 240% of the current FPL.
Participants in the spend-down phase pay the retail price on covered drugs.
After the spend-down is met, each person will have an individual $850 deductible requirement.

12. Why have both SeniorCare & Part D?
Save $$
Reduce the copay, coinsurance, deductible
Part D can provide drug coverage while someone is in the SeniorCare deductible or spend-down phase
SeniorCare can provide drug coverage while someone is in a Part D deductible period

13. Coordination of Benefits
Part D is primary and SeniorCare secondary
If a particular drug is covered by both Part D and SeniorCare:
Part D will pay first
If the resulting Part D co-pay to the beneficiary is greater than $5/$15, SeniorCare will pay the difference.
(Assuming not in a spend-down or deductible period for SeniorCare.)

14. Coordination of Benefits
If the drug is covered by SeniorCare but not Part D:
SeniorCare will cover the cost (assuming no spend-down or deductible period applies).
Enrollee will pay the applicable $5/$15 SeniorCare copay.
This scenario occurs most often due to the beneficiary having a Part D deductible period or potentially not on the Part D plan’s formulary.

15. SeniorCare and TrOOP
“True Out of Pocket” expenses: expenses that count toward a person’s Medicare Part D out-of-pocket threshold of $6,350 (the True Out of Pocket threshold).
SeniorCare Level 1 or 2a:
Only what the member pays counts toward Part D TrOOP
SeniorCare Level 2b or 3:
Both the payments issued by SeniorCare and the member are applied to the TrOOP amount.

16. State Pharmaceutical Assistance Program (SPAP)
Only Parts 2b and 3 of SeniorCare qualify as a SPAP
See definition of SPAP in federal statute 42 CFR
SeniorCare Parts 1 and 2a do not meet the criteria for a SPAP—
excluded because they draw down federal Medicaid matching funds (a section 1115 demonstration program).

17. Enrollment into SeniorCare Can Generate a Special Enrollment Period

18. State Pharmaceutical Asst Program (SPAP) SEP
Levels 2b & 3 only
Allows enrollment into a new plan or to change between plans
Enrollment into new plan typically drops old plan automatically
Exceptions: (cost plans, PFFS plans)

19. Other creditable coverage SEP
Any level
of SrCare
One way pass OUT of a Part D plan or Advantage plan with Rx
Does not allow a change of plan or enrollment into a new plan

20. SeniorCare considerations

21. SeniorCare Easy to use Works alone or with Part D Creditable coverage
PROS
CONS
Easy to use
Works alone or with Part D
Creditable coverage
Low copays & annual fee
No coverage gap
Counts towards TROOP
Does not cover diabetic supplies, i.e. syringes (unless pre-filled)
Vaccines are not covered
Does not work if on Medicaid
People on Medicare Savings Program (MSP) must have Part D as primary
No out-of-network coverage:
Out of state
Hospital observational stay/ER

22. Non-covered medications
Vaccines
Prescription drugs administered in a dr’s office
Drugs that are experimental or cosmetic
OTC drugs such as vitamins and aspirin, even if prescribed by dr
except for insulin
Prescription drugs for which prior authorization has been denied.
Brand name drugs unless medically necessary (per dr)
Drugs from manufacturers who have not signed a rebate agreement with the state.

23. CAUTION
Certain people must enroll in a Part D plan as primary to SrCare
SeniorCare will not work without a Part D plan if the person is deemed eligible for LIS due to being in a Medicare Savings Program (QMB, SLMB, or SLMB+).
SeniorCare remains in place, just requires a primary payer to be billed
These cases apparently show up as quasi-Medicaid in the SeniorCare computer system.

24. CAUTION No drug coverage for out-of-network claims:
Emergency room or hospital observational status
Most hospital inpatient pharmacies are not in-network
No coverage out of state
No self-submission of claims

25. Retroactive Medicaid (Dual Eligibles)
A person is not eligible for SeniorCare if on Medicaid
Card services
LTC Medicaid
Medicaid applications may take months to process & be approved
Medicaid is often approved retroactively
Person is then dis-enrolled retroactively from SrCare
Must utilize LINET for drug coverage
Should be auto-enrolled into a Part D plan going forward

26. Retroactive Medicaid (Dual Eligibles)
LINET will not work in the following situations:
Person opted out of Medicare auto-enrollment
Person is already enrolled in a Part D plan
Person has employer/retiree coverage
Person is in Advantage plan w/o drug coverage
CMS Region V (retroactive dis-enrollment from Adv plan or to MA-PD plan)
SHIP counselor designation required

27. SeniorCare FAQ’s
Q: Does SrCare cover Novolog that is used in an insulin pump? A: Yes

28. SeniorCare FAQ’s
Q: What if my income was slightly higher than I expected and put on my annual application? A: Annual income is determined prospectively from the month of application through the next 12 calendar months. (Good faith, best estimate.)

29. SeniorCare FAQ’s
Q: What if I retire mid-year and my income is much less than I anticipated?
A: A person can submit a new application and $30 fee at anytime to re- establish a new benefit category.
Hint: you would only want to do this if you would go down to a lower level of SeniorCare

30. SeniorCare FAQ’s
Q: If my spouse moved to a NH, do I still have to include his income in my application?
A: SeniorCare counts the income of both spouses if they live together.
Exceptions:
One spouse in a NH and expected to remain there for > 30 days,
Both spouses are in a NH;
Married, but living separately; or
Applicant’s spouse is on SSI.

31. Summary SeniorCare: is creditable coverage
can either be used by itself or with Part D
coordinates well with Part D
does not coordinate with Medicaid
works in nursing homes
if pharmacy accepts SeniorCare, and
if person is not on Medicaid.

32. SeniorCare resources
Medicaid Eligibility Handbook section
WI DHS SeniorCare page and link to application
WI SeniorCare customer service number