Prior Authorization Forms
Outpatient PA Form Inpatient PA Form Subacute PA Form
To review for medical necessity, please submit the following:
- Prior Authorization Request Form
- Current Clinical Notes
- Supporting Documentation
- Physician/Provider Order
For further guidance, please visit the Authorization Requirements page.
These forms and other documents can be found on Prior Authorization Documents or Provider Documents.
Please reach out to the Prior Authorization Department with questions by calling 1-855-839-1032 or emailing paassistants@icarehealthplan.org.
Prior Authorization List (PAL)
Current PAL (pdf)
The PDF can be searched using the F5 option and the excel version of this document can be filtered by category, code, or description.
To prevent disruption of care, iCare does not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment that started prior to the enrollment. iCare may review the services furnished during that active course of treatment against permissible coverage criteria when determining payment.
The Prior Authorization Department has added new codes:
*Effective 4/01/25, the following codes will be added to the list requiring PA:
Procedures: 22836, 22837, 22838, 27278, 51721, 55881, 55882
Neurostimulators:
61889, 61891, 61892, 64596, 64597, 64598, 0908T, 0909T, 0910T, 0911T, 0912T, 0935T
Laboratory/Pathology:
81457, 81458, 81459, 81462, 81463, 81464, 0345U, 0439U, 0440U, 0444U, 0448U, 0449U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0489U, 0493U, 0496U, 0497U, 0498U, 0499U, 0500U, 0506U, 0507U, 0508U, 0509U, 0510U, 0516U
DME/DMS:
A4593, A4594, C9804, C9806, E0468, E0469, E0492, E0493, E0678, E0679, E0680, E0681, E0682, E0683, E0721, E0732, E0733, E0734, E0735, E0736, E0738, E0739, E0743, E2298, E3000, K1037, L1320, L5615, L5783, L5841, L5926, L8720, L8721
Dressings/Skin Substitutes:
A2027, A2028, A2029, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345
Specialty Medications:
J2350 Ocrevus® (ocrelizumab) & Ocrevus Zunovo™ (ocrelizumab and hyaluronidase-ocsq)
J1458 Naglazyme® (galsulfase)
J2323 Tysabri® (natalizumab)
J1930 Lanreotide Products
J2357 Xolair® (omalizumab)
J1300 Soliris® (eculizumab)
J1299 Injection, eculizumab, 2 mg
Intensive Outpatient Services: H2019, H2012
CAR-T: 38225, 38226, 38227, 38228