Part D Prescription Drug Coverage

Part D Prescription Drug Coverage

Independent Care Health Plan’s benefits include the Medicare Part D Prescription Drug program, meaning you do not need to look for a separate program to fulfill your prescription drug needs. Our Medicare Part D Prescription Drug benefit is only available to members of our Medicare plans. If you are already enrolled in a Medicare Advantage Prescription Drug Plan, you must receive your Medicare Prescription Drug benefit through that plan until your coverage begins with your iCare Medicare Plan.

Independent Care Health Plan covers thousands of prescription drugs. The list of drugs that are covered under our Medicare Part D Prescription Drug program is called the formulary. A formulary may also be referred to as a preferred drug list (PDL). We may periodically add, remove, make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we notify the affected enrollee before the change is made. We will send a formulary to you and you can see our complete formulary for your plan.

  • 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

  • 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.

  • What is the Cost to Fill My Prescriptions?
    • Generic Prescription Drugs - $0, $1.20 or $3.30 co-pay (depending on your income level and institutional status)
    • Brand-Name Prescription Drugs - $0, $3.70 or $8.25 co-pay (depending on your income level and institutional status)
    • 90-day supply for a one month co-pay of Tier 1 and Tier 2 formulary medications.

    After $4,950

    • Generic Prescription Drugs - $0
    • Brand-Name Prescription Drugs - $0
  • Extra Help (Low Income Subsidy)

    You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048, 24 hours-a-day/7days-a-week); the Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call, 1-800-325-0778; or your State Medicaid Office.

  • 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.

  • Utilization Management

    For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:

    • Prior Authorization: We require you to get prior authorization for certain drugs. This means that your pharmacist or your physician will need to get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug
    • Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time
    • Step Therapy: In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will 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.
  • Drug Utilization Review

    We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

    • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
    • Drugs that are inappropriate because of your age or gender
    • Possible harmful interactions between drugs you are taking
    • Drug allergies
    • Drug dosage errors

    If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

  • 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.

  • Coverage Determination and Exceptions

    A coverage determination is a decision made by iCare regarding payment for a drug or the types of drugs covered as part of your benefit. If you wish to have iCare review its coverage determination based on your individual circumstances, you may request an exception to a coverage determination. Click here for more information on our coverage determination and exceptions policy.

  • 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.

Modified: 7/18/2017
 

Independent Care Health Plan (iCare) is a Medicare Advantage HMO SNP organization with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in any iCare plan depends on contract renewal. Plans are available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Part B premium is covered by the State if you are a full-dual member. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

  • H2237_IC1453 Approved
 
  • 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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