Formulary Search
The list of drugs that are covered under the
iCare
Medicare Plan is called its 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 by clicking on the link below.
Click here
to download a copy of the
iCare
Medicare Plan formulary.
Click here to perform a search for a specific
prescription drug in our formulary. This link will take you to the
Medicare.gov web site, where you will click on the Formulary Finder
link and then choose the State of Wisconsin to find the specific
prescription drug you are looking for.
Generic Drugs - The
iCare
Medicare Plan covers both brand name drugs and generic drugs. Generic
drugs have the same active-ingredient formula as a brand name drug.
Generic drugs usually cost less than brand name drugs and are rated by the
Food and Drug Administration (FDA) to be as safe and effective as brand name
drugs. Remember, you will have no co-pay for generic prescription
drugs (up to $2,400 annual limit, then $1.00-$2.15 depending on your income). Consult with your
doctor to find out if you can lower your prescription drug costs by using
generic drugs instead of more expensive brand-name drugs.
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.
Drug Utilization & Medication Therapy Management
Methods
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. For example, we will provide up to 31 units
per prescription for Fosamax.
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.
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.
We offer medication therapy
management programs at no additional cost for members who have multiple
medical conditions, who are taking many prescription drugs, or who have high
drug costs. These programs were developed for us by a team of pharmacists
and doctors. We use these medication therapy management programs to help us
provide better coverage for our members. For example, these programs help us
make sure that our members are using appropriate drugs to treat their
medical conditions and help us identify possible medication errors.
We offer a medication therapy
management program for members that meet specific criteria. We may contact
members who qualify for these programs. If we contact you, we hope you will
join so that we can help you manage your medications. Remember, you do not
need to pay anything extra to participate.
If you are selected to join a
medication therapy management program we will send you information about the
specific program, including information about how to get the program.
Please contact Member Services for additional information.
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.
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 of the
iCare
formulary.
Contact Us
Questions? Call us at 1-800-777-4376 (TTY
1-800-947-3529), 7 days-a-week, 8:00 a.m. to 8:00 p.m.
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