List of Covered Drugs/Formularies
2023 List of Covered Drugs

2024 List of Covered Drugs

MSHO 2024 Supplemental Drug Benefit Catalog

 Drug Coverage

• Our List Of Covered Drugs (PDF) (Formulary) shows the Part D and over-the-counter (OTC) covered  drugs by IMCare Classic (HMO SNP).
• Our online search feature lets you see if specific Medicare Part D drugs are covered by IMCare Classic (HMO SNP).
• The list of Medical Assistance covered, Part D-excluded drugs tells you which drugs are covered under your Medical Assistance benefit.
• Most drugs and certain supplies are available up to a 34 day supply.  Certain drugs you take on a regular basis for a chronic or long-term condition are available up to a 90-day supply and are listed on the Itasca Medical Care (IMCare) 90-day supply prescription drug list.
• Our Over-the-Counter drug list tells you which of these drugs are covered by IMCare Classic (HMO SNP) under your Medical Assistance (Medicaid) benefit. The items on the list are covered when you have a prescription from your health care provider or pharmacist.
• If the drug you are taking is not on the list of covered drugs, read your MSHO Member Handbook (PDF) (Evidence of Coverage) to find out what you can do. This includes instructions for both new and current members.
• If you would like help managing your prescription drugs, read about our Medication Therapy Management Program (PDF) and its eligibility requirements. You can also see a sample of the Personal Medication List (PDF).
• For the 2024 Calendar Year,  IMCare has added a Supplemental Drug Benefit for our MSHO members. Please refer to the MSHO 2024 Supplemental Drug Benefit Catalog for more information. 

Restrictions on Covered Drugs

Some drugs have restrictions on coverage. Read about drug restrictions in your MSHO Member Handbook (PDF) (Evidence of Coverage). Specific restrictions are as follows:

• Getting Plan approval in advance: For some drugs, you or your health care provider must get approval from IMCare Classic (HMO SNP) before you fill your prescription. If you don’t get approval, IMCare Classic (HMO SNP) may not cover the drug. This is called Prior Authorization. Prior Authorization Criteria are used to make decisions about whether to cover the drug. Your provider will need to fill out a Prior Authorization form to ask for coverage. 
• Trying a different drug first.: IMCare Classic (HMO SNP) wants you to try lower-cost drugs (that often are as effective) before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, we may require you to try Drug A first. If Drug A does not work for you, we will then cover Drug B. This is called Step Therapy. Step Therapy Criteria are used to make decisions about whether to cover the drug. Your provider will need to fill out a Step Therapy form to ask for coverage.
• Quantity limits: For some drugs, IMCare Classic (HMO SNP) limits the amount of the drug you can have. For example, we might limit how much of a drug you can get each time you fill your prescription. These limits are usually to ensure safe use of the drug. The Quantity Limits for drugs are listed in your List of covered Drugs.. 
• 2023 Prior Authorization and Quantity Limits (PDF)
• 2023 Step Therapy Criteria (PDF) 
• 2024 MSHO Prior Authorization Quantity Limits (PDF) 
• 2024 Step Therapy (ST) Criteria (PDF)

Exceptions/Coverage Determinations

You may ask for an exception to the drug coverage and restriction rules by doing any of the following, fill out the Itasca Medical Care Formulary Exception (PDF). Note: this form must be completed by a health care provider. Completed forms can be mailed or faxed:

Mail

IMCare Classic

Attn: Medicare Appeals Department

1219 SE 2nd Avenue

Grand Rapids, MN 55744-3983

Fax

218-327-5545

Call Member Services at 800-843-9536. TTY users can call 800-627-3529 or 711. Calls to these numbers are free. Hours are:

• October 1 to March 31
  7 days a week 8 a.m. - 8 p.m.
• April 1 - September 30th
  Monday - Friday 8 a.m. - 8 p.m.
• If you contact us, we may need to get more information from your prescribing health care provider. If you need help or have questions, call Member Services.

Transition Period Drug Benefits

Read our Transition Period Drug Benefit Policy to learn about your benefits during a transition period.

Questions/Complaints About Prescription Drug Coverage

If you have a complaint about your prescription drug coverage (e.g., if your drug will not be covered, has restrictions that you don't agree with, or if you think your copay is too high), you can do any of the following:

• Read about "coverage decisions" and "Appeals" in your MSHO Member Handbook (PDF) (Evidence of Coverage).
• Contact IMCare Classic's Member Services at 218-327-6188 or toll free 800-843-9536.
• Tell Medicare about your complaint by visiting the Centers for Medicare and Medicaid Services (CMS) website. You may also call Medicare at 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 877-486-2048. Calls to these numbers are free.
• Ask someone to help you file a complaint. Someone you choose may file a complaint (Grievance) or Appeal for you. The person you name would be your "appointed representative." You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or under State law to act for you. If you want someone to act for you who is not already authorized by the Court or State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. You may call Member Services to learn how to name your appointed representative. You may also fill out the Appointment of Representative Form (PDF). Once you have filled out the form, you should print it and mail or fax it to Itasca Medical Care:

Mail

IMCare Classic

Attn: Medicare Appeals Department

1219 SE 2nd Avenue

Grand Rapids, MN 55744-3983

Fax

218-327-5545

Reimbursement

We cannot pay you back for most medical bills that you pay. State and Federal laws prevent us from paying you directly. The exception is if you pay for Part D prescription drugs. If you paid for a drug that you think we should have covered, call Member Services at 800-843-9536. TTY users can call 800-627-3529 or 711. Calls to these numbers are free. Hours are:

• October 1 - March 31
  7 days a week 8 a.m. - 8 p.m.
• April 1 - September 30
  Monday - Friday 8 a.m. - 8 p.m.
• Or, you can print a Medicare Prescription Drug Claim Form (PDF) and follow the instructions to complete and submit it to us for review.