Part D Coverage Determinations, Exceptions, and Appeals

Part D Coverage Determinations, Exceptions, and Appeals


  • What is a Coverage Determination?

    The coverage determination made by iCare is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered you should contact iCare and ask us for a coverage determination. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. If we deny your request (this is sometimes called an “adverse coverage determination”), you can “appeal” the decision by going on to Appeal Level 1 (see below). If we fail to make a timely coverage determination on your request, it will be automatically forwarded to the Independent Review Entity for review.

    The following are examples of coverage determinations:

    • You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment. You can call us at 1-800-777-4376 (TTY 1-800-947-3529), 24 hours-a-day, 7 days-a-week (office hours: Monday-Friday, 8:30 a.m. to 5:00 p.m.). to get help in making this request.
    • You ask for a Part D drug that is not on your plan's list of covered drugs (called a "formulary"). This is a request for a "formulary exception." You can call us at 1-800-777-4376 (TTY 1-800-947-3529) to ask for this type of decision.
    • You ask for an exception to our plan’s utilization management tools - such as dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. You can call us at 1-800-777-4376 (TTY 1-800-947-3529) to ask for this type of decision.
    • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception." You can call us at 1-800-777-4376 (TTY 1-800-947-3529) to ask for this type of decision.
    • You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan. You can call us at 1-800-777-4376 (TTY 1-800-947-3529) to make a request for payment or coverage for drugs provided by an out-of-network pharmacy or in a physician’s office. When we make a coverage determination, we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of our Medicare Plans apply to your specific situation. Your Evidence of Coverage and any amendments you may receive describe the Part D prescription drug benefits covered by your plan, including any limitations that may apply to these benefits. Your Evidence of Coverage also lists exclusions (benefits that are "not covered" by your iCare Medicare Plan)

    When we make a coverage determination, we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of iCare Medicare Plan apply to your specific situation. Your Evidence of Coverage and any amendments you may receive describe the Part D prescription drug benefits covered by iCare Medicare Plan, including any limitations that may apply to these benefits. Your Evidence of Coverage also lists exclusions (benefits that are "not covered" by the iCare Medicare Plan).

    Please refer to your Evidence of Coverage, Chapter 9, Section 11 if you have a complaint (grievance), for more information. If you need information about a coverage determination or decision (including exceptions) and the appeals process, refer to Chapter 9, Sections 5-10

    You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

    You may print this form and send it to the address or fax listed at the top of the form:

    Coverage Determination Request Form

    Or, you may click here to submit a coverage determination request through the web. You will be redirected to the website of our Pharmacy Benefits Manager.

  • Who May Ask For A Coverage Determination/Appoint a Representative?

    You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a CMS Appointment of Representative form (CMS-1696) and include it with your written statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at:

    Independent Care Health Plan
    1555 N. RiverCenter Dr., Suite 206
    Milwaukee, WI 53212

    Print this form to appoint your representative:

    CMS Appointment of Representative form (CMS-1696)

    You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

  • Asking For a "Standard" or "Fast" Coverage Determination

    Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard timeframe?

    A decision about whether we will cover a Part D prescription drug can be a "standard" coverage determination that is made within the standard timeframe (typically within 72 hours; see below), or it can be a "fast" coverage determination that is made more quickly (typically within 24 hours; see below). A fast decision is sometimes called an "expedited coverage determination."

    You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.)

  • Asking for a Standard Decision

    To ask for a standard decision, you, your doctor, or your appointed representative should call us at 1-800-777-4376 (TTY 1-800-947-3529). Or, you can deliver a written request to Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212 or fax it to (414) 231-1092.

    Or, you may click here to submit a coverage determination request through the web. You will be redirected to the website of our Pharmacy Benefits Manager.

  • Asking For a Fast Decision

    You, your doctor, or your appointed representative can ask us to give a fast decision (rather than a standard decision) by calling us at 1-800-777-4376 (TTY 1-800-947-3529). Or, you can deliver a written request to Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212 or fax it to (414) 231-1092.

    Or, you may click here to submit a coverage determination request through the web. You will be redirected to the website of our Pharmacy Benefits Manager.

    • If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.
    • If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will notify you by phone and send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "grievance" if you disagree with our decision to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our decision within the 72 hour standard timeframe.
  • What Happens When You Request a Coverage Determination?

    What happens, including how soon we must decide, depends on the type of decision.

    1. For a standard coverage determination about a Part D drug, which includes a request about payment for a Part D drug that you already received.
    Generally, we must give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception, or an exception from utilization management rules – such as dosage or quantity limits or step therapy requirements), we must give you our decision no later than 72 hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary. If you are requesting an exception, you should submit your prescribing physician's supporting statement with the request, if possible.
    We will notify you by phone and give you a decision in writing about the prescription drug you have requested. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" explains how to file this appeal.
    If you have not received an answer from us within 72 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
    2. For a fast coverage determination about a Part D drug that you have not received.
    If you receive a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review – sooner if your health requires. If your request involves a request for an exception, we will give you our decision no later than 24 hours after we have received your physician's "supporting statement," which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.

    We will notify you by phone and give you a decision in writing about the prescription drug you have requested. If we do not approve your request, we must explain why, and tell you of your right to appeal our decision. The section "Appeal Level 1" explains how to file this appeal.

    If we decide you are eligible for a fast review, and you have not received an answer from us within 24 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

    If we do not grant you or your physician's request for a fast review, we will give you our decision within the standard 72 hour timeframe discussed above. We will tell you about our decision not to provide a fast review by phone, we will also send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a “grievance” if you disagree with our decision to deny your request for a fast review, and will explain that we will automatically give you a fast decision if you get a doctor’s support for a fast review.

  • What Happens If We Decide Completely In Your Favor?

    If we make a coverage determination that is completely in your favor, what happens next depends on the situation.

    1. For a standard decision about a Part D drug, which includes a request about payment for a Part D drug that you already received.
    We must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 72 hours after we have received your physician's "supporting statement." If you are requesting reimbursement for a drug that you already paid for and received, we must send payment to you no later than 30 calendar days after we receive the request.
    2. For a fast decision about a Part D drug that you have not received.
    We must authorize or provide you with the benefit you have requested no later than 24 hours of receiving your request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 24 hours after we have received your physician's "supporting statement."
  • How Can You Request An Exception To The Plan’s Formulary?

    You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

    • You can ask us to cover your drug even if it is not on our formulary.
    • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
    • You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a brand name drug, you can ask us to cover it as a generic drug instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

    Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

    In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception request.

    If we approve your exception request, our approval is valid for one year, so long as your doctor continues to prescribe the drug for you, and it continues to be safe and effective for treating your condition.

    The results of the coverage determination will be sent to you by mail, and the initiator of the request will be contacted by phone.

  • What Happens if We Deny Your Request?

    If we deny your request, we will inform you by phone and send you a written decision explaining the reason why your request was denied. We may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the decision. (See Appeal Level 1).

  • What is an Appeal?

    An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

    Appeal Level 1: If we deny part or all or part of your request in our coverage determination, you may ask us to reconsider our decision. This is called an "appeal" or "request for redetermination."

    Please call us at 1-800-777-4376 (TTY 1-800-947-3529) if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our decision is not what you requested. When we receive your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.

    How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for, or authorization of a Part D benefit (that is, a Part D drug that you have not yet received). If your appeal concerns a decision we made about authorizing a Part D benefit that you have not received yet, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast coverage determination. Please see the discussion under "Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard timeframe?" and "Asking for a fast decision."

  • Asking for an Appeal

    To ask for an appeal, you, your doctor, or your appointed representative should call us at 1-800-777-4376 (TTY: 1-800-947-3529). Or, you can deliver a written request to Independent Care Health Plan, 1555 N. RiverCenter Dr, Suite 206, Milwaukee, WI 53212 or fax it to 414-231-1092.

    You may print this form and send it to iCare.
    Redetermination Request Form

    Or, you may click here to submit an appeal request through our secure web form.

  • What if You Want A Fast Appeal?

    The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination. You, your doctor, or your appointed representative can ask us to give a fast appeal (rather than a standard appeal). Remember, that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically treat you as eligible for a fast appeal. For information on how to submit an appeal, see the section above (Asking for an Appeal).

  • Getting Information to Support Your Appeal

    We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.

    You can give us your additional information in any of the following ways:

    • In writing, to Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212.
    • By fax, at (414) 231-1092.
    • By telephone – if it is a fast appeal – at 1-800-777-4376 (TTY 1-800-947-3529).
    • In person, at 1555 N. RiverCenter Dr, Suite 206.

    You also have the right to ask us for a copy of information regarding your appeal. You can call or write us at 1-800-777-4376 (TTY 1-800-947-3529), Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212.

  • Who May File Your Appeal of the Coverage Determination?

    The rules about who may file an appeal are the same as the rules about who may ask for a coverage determination. An appeal may be filed by you, your appointed representative, or your prescribing physician.

  • How Soon Must You File Your Appeal?

    You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline.

  • How Soon Must We Decide On Your Appeal?

    How quickly we decide on your appeal depends on the type of appeal:

    1. For a standard decision about a Part D drug, which includes a request for reimbursement for a Part D drug you already paid for and received.
    After we receive your appeal, we have up to 7 calendar days to give you a decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
    2. For a fast decision about a Part D drug that you have not received.
    After we receive your appeal, we have up to 72 hours to give you a decision, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
  • What Happens Next if we Decide Completely in Your Favor?
    1. For a decision about reimbursement for a Part D drug you already paid for and received.
    We must send payment to you no later than 30 calendar days after we receive your request to reconsider our coverage determination.
    2. For a standard decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for as quickly as your health requires, but no later than 7 calendar days after we received your appeal.
    3. For a fast decision about a Part D drug you have not received.
    We must authorize or provide you with the Part D drug you have asked for within 72 hours of receiving your appeal – or sooner, if your health would be affected by waiting this long.
  • What Happens Next if We Deny Your Appeal?

    If we deny any part of your appeal, you or your appointed representative have the right to ask an independent organization, to review your case. This independent review organization contracts with the federal government and is not part of iCare's Medicare Plan.

    If you would like to inquire about the status of a coverage determination, please call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529).

    See your Evidence of Coverage, Section 11, "Appeals and Grievances: What To Do If You Have Complaints About Your Part D Prescription Drug Benefits," for more information.


Modified: 7/24/2017
 

  • H2237_IC1453 Approved
 
  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
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