Members

iCare FamilyCare Partnership (HMO)
Formulary Search

What is a Prescription Drug Formulary?

iCare Family Care Partnership (HMO) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug (Medicaid-only members do not have to pay for their drugs). If we make any formulary change that limits our members' ability to fill their prescriptions, we will notify the affected enrollees before the change is made.

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

Click here to find out what drugs are covered in our formulary, or call Member Services at 1-800-777-4376 (TTY 1-800-947-3529), 7 days-a-week, 8:00 a.m. to 8:00 p.m.

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 - iCare Family Care Partnership (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: iCare Family Care Partnership Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from iCare Family Care Partnership (HMO) before you fill your prescriptions. If you don't get approval, iCare Family Care Partnership (HMO) may not cover the drug.
  • Quantity Limits: For certain drugs, iCare Family Care Partnership (HMO) limits the amount of the drug that iCare Family Care Partnership (HMO) will cover. For example, iCare Family Care Partnership (HMO) provides 60 capsules per prescription for Celebrex. This may be in addition to a standard one month or three month supply.
  • Step Therapy: In some cases, iCare Family Care Partnership (HMO) requires you to first try certain drugs 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, iCare Family Care Partnership Plan may not cover drug B unless you try Drug A first. If Drug A does not work for you, iCare Family Care Partnership Plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page T-1.

You can ask iCare Family Care Partnership Plan to make an exception to these restrictions or limits. See the section, “How do I request an exception to the iCare Family Care Partnership (HMO) formulary?” on page 6 for information about how to request an exception.

What are over-the counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. iCare Family Care Partnership Plan pays for certain OTC drugs as part of your Medicaid benefit. iCare Family Care Partnership (HMO) will provide these OTC drugs at no cost to you. The cost to iCare Family Care Partnership (HMO) of these OTC drugs will not count toward your total drug costs. Over the counter drugs require a legal prescription in order to be covered. The list of covered OTC drugs is on page 12 of the formulary. Partnership members will have access to all Medicaid covered over-the-counter drugs. For members enrolled in Medicare, the cost to iCare Family Care Partnership (HMO) of these OTC drugs will not count toward your total Medicare Part D drug costs.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that iCare Family Care Partnership (HMO) does not cover your drug, you have two options:

  • You can ask Member Services for a list of similar drugs that are covered by iCare Family Care Partnership (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by iCare Family Care Partnership Plan.
  • You can ask iCare Family Care Partnership (HMO) to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the iCare Family Care Partnership (HMO) Formulary?

You can ask iCare Family Care Partnership (HMO) 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, iCare Family Care Partnership Plan 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.

Generally, iCare Family Care Partnership (HMO) will only approve your request for an exception if the alternative drugs included on the plan's formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you are requesting a formulary, or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.

What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact iCare Family Care Partnership (HMO) for more details.

Programs to Help Members Use Drugs Safely

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

  • Possible medication errors.
  • Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
  • Drugs that may not be safe or appropriate because of your age or gender.
  • Certain combinations of drugs that could harm you if taken at the same time.
  • Prescriptions written for drugs that have ingredients you are allergic to.
  • Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of medications, we will work with your doctor to correct the problem.

What Types of Drugs May Be Covered Under Medicare Part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact iCare Family Care Partnership (HMO) for more details.

  • Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
  • Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
  • Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
  • Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia
  • Injectable Drugs: Most injectable drugs administered incident to a physician's service.
  • Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.
  • Some Oral Cancer Drugs: If the same drug is available in injectable form.
  • Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
  • Inhalation and Infusion Drugs provided through DME.

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. Our mailing and walk-in address is: Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212.

 

  
 
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Call 1-800-777-4376 (TTY: 1-800-947-3529), from 8:00 a.m to 8:00 p.m.,
7 days-a-week, for further information about iCare.

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