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Coverage Determinations, Exceptions, and Appeals

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How Can You Request an Exception to the Plan’s Formulary?

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 cover your drug even if it is not on our formulary.
• 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 one 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.

What Happens if We Deny Your Request?

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).

What is an Appeal?

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.

Appeal Level 1: If we deny part or all or part of your request in our coverage determination, you may ask us to reconsider our decision. This is called an "appeal" or "request for redetermination."

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."

Asking for an Appeal

To ask for an appeal, 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.

You may print this form and send it to iCare.
Redetermination Request Form

Or, you may click here to submit an appeal request through our secure web form.

What if you Want a Fast Appeal?

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). 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. For information on how to submit an appeal, see the section above (Asking for an Appeal).

Getting Information to Support Your Appeal

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 206, Milwaukee, WI 53212.
• By fax, at (414) 231-1092.
• By telephone – if it is a fast appeal – at 1-800-777-4376 (TTY 1-800-947-3529).
• In person, at 1555 N. RiverCenter Dr, Suite 206.

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 206, Milwaukee, WI 53212.

Who May File Your Appeal of the Coverage Determination?

The rules about who may file an appeal are the same as the rules about who may ask for a coverage determination. An appeal may be filed by you, your appointed representative, or your prescribing physician.

How Soon Must You File Your Appeal?

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.

How Soon Must we Decide on Your 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.

What Happens Next if we Decide Completely in Your Favor?

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.

What Happens Next if we Deny Your Appeal?

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.

Contact Us

Questions? Call us at 1-800-777-4376 (TTY 1-800-947-3529), 7 days-a-week, 8:00 a.m. - 8:00 p.m.

Medicare

• iCare Medicare Benefits and Services
• Part D Prescription Drug Coverage
• Prescription Drug Information and Formulary
• Grievance Policy
• Exception and Appeals Policy
• Coverage Limitations