Wisconsin Medicare Prescription Drug Plans

To find out if the prescription medications you take are subject to Prior Authorization or Step Therapy restrictions, type the name of the drug in the Search box on the online formulary page box above. You may also review the documents below that explain our prior authorization and step therapy restrictions. If your prescription does require Prior Authorization or Step Therapy, please download and have your prescribing doctor complete a Coverage Determination Request Form.

• Prior Authorization Medications

If you have requested a Coverage Determination or Redetermination (Appeal) and you would like to check the status, please call us at 1-800-688-1604 (TTY: 1-800-716-3231) 24 hours a day, seven days a week

You may also find out if a drug you take is subject to additional requirements or Quantity Limit restrictions by reviewing the WPS MedicareRx Plan formulary or inquire by phone by calling Customer Service.

The WPS MedicareRx Plan (PDP) conducts drug utilization reviews for all our customers to make sure that they are getting safe and appropriate care. These reviews are especially important for customers who have more than one doctor who prescribes their medications. Drug utilization reviews are conducted 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:

• Drug allergies
• Possible medication errors
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

• Medicare Part-D Prescription Drug Claims Form

Brand and Generic Drugs

A formulary is a list of the brand and generic drugs covered by your plan. WPS MedicareRx Plan covers both brand drugs and generic drugs. Generic equivalents have the same active ingredient(s) as a brand drug. Generic drugs usually cost less than brand drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand drugs.

Size of Formulary

The WPS MedicareRx Plan (PDP) formulary includes more than 3,000 covered medications, making it one of the nation's largest formularies.

30-Day Notice

We may periodically add or remove a drug, make changes to coverage rules on certain drugs, or change how much you pay for a drug. If we make any formulary change that limits your ability to fill prescriptions, we will notify you at least 30 days before the change is made. Note that if the Food and Drug Administration finds that a drug on the formulary is unsafe or if the drug's manufacturer removes the drug from the market, we immediately remove the drug from our formulary and then notify you of the change.

Coverage

Some drugs may be covered under Medicare Part B or Medicare Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the receipt of the drug to make the determination.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For full information on WPS MedicareRx Plan benefits, call our Customer Service.

You may be able to get a temporary supply if your drug is not on the Drug List or is restricted. Here are things you can do:

• You may be able to get a temporary supply of the drug (only customers in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

1. The change to your drug coverage must be one of the following types of changes:
   • The drug you have been taking is no longer on the plan's Drug List.
   -- or --
   • The drug you have been taking is now restricted in some way (Section 4 of your Evidence of Coverage explains some of these restrictions).
   
   
2. You must be in one of the situations described below:
   • For those customers who are new or who were in the plan last year:
     If you are a new customer and your drug is no longer covered or newly restricted in some way, we will cover a temporary supply of your drug during the first 90 days of your membership. If you were in the plan last year and your drug is no longer covered or newly restricted in some way, a temporary supply of your drug will only be covered during the first 90 days of the calendar year. The temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
   • For those customers who have been in the plan for more than 90 days and reside in a long-term care facility and need a supply right away:
     We will cover a 31-day supply or less if your prescription is written for fewer days. If your prescription is for fewer days, we will allow multiple fills up to a maximum of a 31-day supply.
   • For those who have been a customer of the plan for more than 90 days and experience a level of care change, which is defined below, can ask for a 31-day supply:
     • Entering a long-term care facility from a hospital or other setting;
     • Leave a long-term care facility and return to the community;
     • Are discharged from a hospital to a home;
     • End a skilled nursing facility stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan formulary;
     • Revert from hospice status to standard Medicare Part A and B benefits and are discharged from psychiatric hospitals with medication regimens that are highly individualized.

To ask for a temporary supply, call Customer Service 1-800-688-1604 (TTY: 1-800-716-3231), 24 hours a day, seven days a week.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.