Part D Prescription Drug Coverage

iCare Family Care Partnership
Part D Prescription Drug Coverage


Part D Prescription Drug Coverage

iCare Family Care Partnership (HMO SNP) covers Wisconsin Medicaid drugs, and people with Medicare also receive coverage for Medicare Part B and Medicare Part D prescription drugs. The iCare Family Care Partnership (HMO SNP) covers thousands of prescription drugs.

iCare Family Care Partnership (HMO SNP) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug (Medicaid-only members do not have to pay for their drugs). If we make any formulary change that limits our members' ability to fill their prescriptions, we will notify the affected enrollees before the change is made. Click here to view our current Comprehensive Formulary or click here for our 2018 Comprehensive Formulary.

  • What Types Of Drugs Maybe Covered Under Medicare Part B?

    Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact iCare Family Care Partnership (HMO SNP) for more details.

    • Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision
    • Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare
    • Erythropoietin (Epoetin Alfa or Epogen©): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia
    • Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia
    • Injectable Drugs: Most injectable drugs administered incident to a physician's service
    • Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility
    • Some Oral Cancer Drugs: If the same drug is available in injectable form
    • Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen
    • Inhalation and Infusion Drugs provided through DME
  • Covered OTC Medications

    OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. iCare Family Care Partnership (HMO SNP) pays for certain OTC drugs as part of your Medicaid benefit. iCare Family Care Partnership (HMO SNP) will provide these OTC drugs at no cost to you. The cost to iCare Family Care Partnership (HMO SNP) of these OTC drugs will not count toward your total drug costs. Over the counter drugs require a legal prescription in order to be covered. The list of covered OTC drugs is on page 14 of the formulary. Partnership members will have access to all Medicaid covered over-the-counter drugs. For members enrolled in Medicare, the cost to iCare Family Care Partnership (HMO SNP) of these OTC drugs will not count toward your total Medicare Part D drug costs.

  • What is the Cost to Fill My Medicare Part D Prescriptions? (Medicare Members Only)

    Initial Coverage

    • Generic Prescription Drugs (including brand drugs treated as generics): $0 Co-pay
    • Brand Name Prescription drugs: $0 Co-pay
      • Members who only have Medicaid coverage do not have a copayment for generic or brand drugs.
    • Catastrophic Coverage: You pay nothing

    Extra Help (Low Income Subsidy)

    Since you must have Wisconsin Medicaid to enroll in Partnership, you will qualify for extra help with Medicare prescription drug plan costs, and your premium and costs at the pharmacy will be lower. Your monthly premium will be $0. When you join Partnership, Medicare will tell us how much extra help you are getting with costs at the pharmacy. Then we will let you know the amount you will pay. If you are not getting this extra help you can see if you qualify by calling:

    • 1-800-MEDICARE 91-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours-a-day/7 days-a-week
    • The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 or Wisconsin Medicaid at 1-800-362-3002. TTY users should call 1-800-362-3002

    What if you believe you have qualified for extra help and you believe that you are paying an incorrect co-payment amount?

    If you believe you have qualified for extra help and you believe that you are paying an incorrect co-payment amount when you get your prescription at a pharmacy, our Plan has established a process that will allow you to either request assistance in obtaining evidence of your proper co-payment level, or, if you already have the evidence, to provide this evidence to us. Independent Care Health Plan follows CMS' Best Available Evidence policy (BAE). Please contact Customer Service 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.), for assistance with obtaining evidence of your proper co-payment level or for more information on providing this information to us.

    When we receive the evidence showing your co-payment level, we will update our system or implement other procedures so that you can pay the correct co-payment when you get your next prescription at the pharmacy. Please be assured that if you overpay your co-payment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future co-payments. Of course, if the pharmacy hasn’t collected a co-payment from you and is carrying your co-payment as a debt owed by you, we may make the payment directly to the pharmacy. If a State paid on your behalf, we may make payment directly to the State. Please contact Customer Service if you have questions.

  • Where Can I Get My Prescriptions Filled?

    Members must use network pharmacies to obtain their prescription drugs, except under non-routine cases when you cannot make it to a network pharmacy. A network pharmacy is a pharmacy that has contracted with the iCare, where beneficiaries access prescription drug benefits provided by the iCare. Click here for more information about network pharmacies and out of network coverage rules.

  • Are There Any Restrictions On My Coverage?

    Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

    • Prior Authorization: iCare Family Care Partnership (HMO SNP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from iCare Family Care Partnership (HMO SNP) before you fill your prescriptions. If you don’t get approval, iCare Family Care Partnership (HMO SNP) may not cover the drug
    • Quantity Limits: For certain drugs, iCare Family Care Partnership (HMO SNP) limits the amount of the drug that iCare Family Care Partnership (HMO SNP) will cover. For example, iCare Family Care Partnership (HMO SNP) provides 60 capsules per prescription for Celebrex. This may be in addition to a standard one month or three month supply
    • Step Therapy: In some cases, iCare Family Care Partnership (HMO SNP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, iCare Family Care Partnership (HMO SNP) may not cover drug B unless you try Drug A first. If Drug A does not work for you, iCare Family Care Partnership (HMO SNP) will then cover Drug B
    • Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug

    You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. Click here for more information on how to request an exception to the formulary.

    You can find out if your drug has any additional requirements or limits by looking in the formulary. You can ask iCare Family Care Partnership (HMO SNP) to make an exception to these restrictions or limits. See the section of the formulary, “How do I request an exception to the iCare Family Care Partnership (HMO SNP) formulary?” for information about how to request an exception.


    Coverage Limitations

    Drugs must be prescribed for a use that is approved by the FDA or documented in at least one of the specific peer-review compendia identified by the Centers for Medicare and Medicaid (CMS) to be covered. Click here for more information on these limitations.

  • Medication Therapy Management (MTM) Program

    iCare contracts with OutcomesMTM™ to offer Medication Therapy Management services to all iCare Medicare Plan members. Through OutcomesMTM, specially trained Personal Pharmacists are identified in communities throughout Eastern Wisconsin. For more information about our MTM program, click here.

  • Programs to Help Members Use Drugs Safely

    We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

    We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

    • Possible medication errors
    • Drugs that may not be necessary because you are taking another drug to treat the same medical condition
    • Drugs that may not be safe or appropriate because of your age or gender
    • Certain combinations of drugs that could harm you if taken at the same time
    • Prescriptions written for drugs that have ingredients you are allergic to
    • Possible errors in the amount (dosage) of a drug you are taking

    If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.

  • Grievance

    A grievance is any complaint about iCare or one of our network pharmacies that does not involve a coverage or payment decision. Click here to find out how to file a grievance.

  • Plan Transition Process

    Click here to see our plan transition process if you need some help in finding out what to do if your temporary supply of non-formulary prescription drugs is about to run out or to find out what options you have if your present prescription drug is taken off the iCare formulary.

Notification:
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Modified: 9/29/2017
 

The iCare Family Care Partnership (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in iCare Family Care Partnership depends on contract renewal. The benefit information provided herein is a brief summary, not a comprehensive description of available benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1 of each year. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help that you receive, please contact the plan for further details. You must receive all routine care from plan providers. Limitations, copayments, and restrictions may apply. This plan is available to anyone who has both Medical Assistance from the State and Medicare and functionally eligible as determined by the State of Wisconsin Long-Term Care Functional Screen. For more information, contact the plan. For more information about Medicare benefits and services, including general information regarding the health or Part D benefit, contact 1-800-MEDICARE (1-800-633-4227) or visit http://www.medicare.gov; TTY users should call 1-887-486-2048, 24 hours a day, 7 days a week. For more information about State Medicaid benefits call the Department of Health Services at 1-800-362-3002 (TTY 1-888-701-1251) or visit http://dhs.wisconsin.gov/medicaid. For more information about long-term care options available to you in your county contact the Aging and Disability Resource Centers. The Resource Center can also assist you with information about eligibility and enrollment.

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  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
  • Customer Service: 1-800-777-4376
    • 24 hours-a-day, 7 days-a-week
    • (Office Hours: Monday-Friday, 8:30 a.m. to 5:00 p.m.)
  • TTY: 1-800-947-3529
  • Fax: 414-231-1092
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