Members

2011 iCare Medicare Plan
Prescription Drug Information and Formulary

The list of drugs that are covered under the iCare Medicare Plan is called the 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 comprehensive 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 a $0, $1.10 or $3.30 co-pay for generic prescription drugs (depending on your income level.) For all other prescription drugs, you will pay a co-pay of $0, $3.30 or $6.30 (depending on your income level.) After your yearly out-of-pocket drug costs reach $4,550, you pay a $0 co-pay. 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 Program

Utilization Management

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.
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.

Drug Utilization Review

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.

Medication Therapy Management Program

We offer a medication therapy management program at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. This program was developed for us by a team of pharmacists and doctors. We use the medication therapy management program to help us provide better coverage for our members. For example, this program helps us make sure that our members are using appropriate drugs to treat their medical conditions and helps 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

For full information on iCare Medicare Plan benefits, call our Member Services Department at 1-800-777-4376 (TTY 1-800-947-3529), 7 days-a-week, 8:00 a.m. to 8:00 p.m.

Last Updated: 12/1/2010