Members

Exception and Appeals Policy

What is a Coverage Determination?

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)

Who may ask for a coverage determination?

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:

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.

Continued...

Medicare

• iCare Medicare Benefits and Services
• iCare Medicare Plan-Northeast Plan Overview
• Grievance Policy
• Exception and Appeals Policy
• Coverage Limitations