Exceptions and Appeals: What to do if you have complaints
about your Part D prescription drug benefits
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), 7 days-a-week, 8:00 a.m. -
8:00 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), 7 days-a-week, 8:00 a.m. -
8:00 p.m. 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),
7 days-a-week, 8:00 a.m. -
8:00 p.m. 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), 7 days-a-week, 8:00 a.m. -
8:00 p.m. 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), 7
days-a-week, 8:00 a.m. -
8:00 p.m. 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
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).
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.
Print this form and send to
iCare:
Coverage Determination Request Form (for use by member)
Print this form and provide to
your prescriber:
CMS
Model Coverage Determination Request Form (for use by
provider)
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 202A
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.
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.)
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
202A, Milwaukee, WI 53212 or fax it to
(414) 231-1092.
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 202A, Milwaukee, WI
53212 or fax it to
(414) 231-1092. If you need to make a request outside of
regular weekday business hours, please call your care coordinator or
dial MedImpact at 1-800-910-4743. Be sure to ask for a “fast,”
"expedited," or “24-hour” review.
-
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.
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."
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 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 the
remainder of the plan 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.
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).
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.
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.”
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 202A, Milwaukee, WI
53212.
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 202A, Milwaukee, WI 53212.
The rules about who may file an
appeal are almost the same as the rules about who may ask for a coverage
determination. For a standard request, you or your appointed
representative may file the request. A fast appeal may be filed by you,
your appointed representative, or your prescribing physician.
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.
To file a standard appeal, you
can send the appeal to us in writing at
Independent Care Health Plan,
1555 N. RiverCenter Dr., Suite 202A, Milwaukee, WI 53212,
or you can call us at
1-800-777-4376 (TTY 1-800-947-3529).
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) 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 202A, Milwaukee, WI 53212,
or fax it to
(414) 231-1092. If you need to
make a request outside of regular weekday business hours, please call
your care coordinator or dial MedImpact at 1-800-910-4743.
Be sure to ask for a “fast,” "expedited," or “72-hour” review.
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.
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.
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.
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
the
iCare
Medicare Plan.
If you would like to inquire about the status of a
coverage determination, please call Member Services
at 1-800-777-4376 (TTY 1-800-947-3529), 7 days-a-week, 8:00 a.m. -
8:00 p.m.
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.
