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.