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 if you have a complaint (grievance) or if you need information about a coverage determination or decision (including exceptions and the appeal process). 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 submit an online coverage determination request through the web. You will be redirected to the website of our Pharmacy Benefits Manager.

You can ask for an coverage determination yourself, your treating physician can file one for you, 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, 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) or an equivalent form and include it with your request for a coverage determination. This will give the person you name legal permission to act as your appointed representative. This form must be sent to us at:

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

You can print this form to appoint your representative:

CMS Appointment of Representative form (CMS-1696)

You do not need to have an Appointment of Representative form completed in order for your treating physician to submit a Coverage Determination request on your behalf.  

You do not need to use this specific Appointment of Representative form. You can use this form or any equivalent document that contains the same components.

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.

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.)

How do I ask 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 submit a coverage determination request through the web. You will be redirected to the website of our Pharmacy Benefits Manager.

How Do I Ask 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 to submit an online 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, 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 the Decision is Completely In My 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."