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Prior Authorization Documents

This is the place for providers to find Prior Authorization-related forms and other documents.

Pro Tip: You can also find them on the Provider Documents page, but we thought: Why not make it as easy for you as possible? 

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2019 Comprehensive Formulary-iCare FCP Medicaid Only-Updated 11.30.19

A comprehensive list of covered drugs/formulary for those enrolled in the iCare Family Care Partnership plan but have Medicaid only

2019 Comprehensive Formulary-iCare FCP Plan-Updated 11.30.19

Comprehensive list of covered drugs for those in the iCare Family Care Partnership Plan and who also have Medicare

2019 Comprehensive Formulary-iCare Medicare Plans-Updated 11.30.19

Comprehensive list of covered drugs/formulary for iCare Medicare plan, Aurora CompleteCare, and Lakeland Care+Health plan

2019 Part D Prior Authorization Criteria-Updated 12.1.19

Members may need drugs that require prior authorization. This means before the plan will cover a particular drug, you must show the plan you meet certain criteria for you to have that particular drug. Plans also do this to be sure these drugs are used correctly.

2019 Step Therapy Rx Drug Criteria-Updated 12.1.19

Step therapy means trying less expensive options before "stepping up" to drugs that cost more. It works to make sure iCare members get the safest, most effective and reasonably-priced drug available.

Behavioral Health and AODA FAQs

This document answers frequently asked questions by providers about Behavioral Health and AODA as related to claims and prior authorization for treatment programs received by iCare members.

iCare Personal Emergency Response System (PERS) Enrollment Form

In-home Personal Emergency Response System (PERS) is provided by iCare as a supplemental Medicare benefit. PERS is indicated for personal use for members with medical conditions resulting in functional limitations or incapacitation that prevent the member from using other means of summoning assistance in an emergency. To request prior authorization for the Personal Emergency Response System, please submit the iCare Personal Emergency Response System (PERS) Enrollment Form.

iCare Remit Reason Codes

Remittance Reason Codes provide additional explanation for a claim

Medication Request Form

This form is used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is no suitable alternate available.

Part D Transition Process

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

PA-Testing for Drugs of Abuse

All outpatient drugs of abuse testing, both presumptive and definitive, require a prior authorization request.

Personal Care Screening Tool - Instructions

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Here are instructions to do so.

Personal Care Screening Tool - MS Word Format

ForwardHealth requires persons who are requesting authorization for personal care (PC) service to complete and submit the Personal Care Screening Tool. Here is the form in Microsoft Word format.

Personal Care Screening Tool (Form)

The Personal Care Screening Tool was developed to assist providers in determining the number of units to request for PA (prior authorization) of medically necessary personal care services that are to be provided by a PCW (personal care worker). Here is the form in PDF format.

Prior Authorization Procedure Specific Listing Q1 2017 effective January 1 2017

This document provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Procedure Specific Listing Q1 2018 effective January 1 2018

This Procedure provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage.

Prior Authorization Procedure Specific Listing Q3 2017 effective July 2017

This Procedure provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Procedure Specific Listing Q3 2018 effective July 15 2018

This document provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Procedure Specific Listing Q3 2019 effective July 19 2019

This document provides specific codes that require a prior authorization. Presence of a code does not guarantee coverage. All referrals for second and third (or additional) opinions, as well as out of state providers require prior authorization.

Prior Authorization Request Form

For a procedure to be considered for prior authorization, please complete this brief form. Receipt of an approved prior authorization does not guarantee coverage or payment by iCare.

Prior Authorization Requirements - In Home Meals

In-home meal service is provided by iCare as a supplemental Medicare benefit to members immediately following surgery or an inpatient hospital stay, for a temporary duration when ordered by a practitioner.

Prior Authorization Subacute Request Form

Prior Authorization Subacute Request Form

Psych Testing Guidelines

Behavioral health providers use this form to provide information in conjunction with the prior authorization request about a member's psychological case background, and information relating to referred testing for a member.

Telehealth Notification Form

Telehealth is a benefit provided by iCare as a supplemental benefit for members enrolled in Medicare and for members in the Medicaid lines of business for behavioral health access, as needed. Telehealth may be used by members from home using the American Well application, or by using the American Well Kiosk located at iCare. To request prior authorization for Telehealth, please submit the Telehealth Notification Form

Leaving iCareHealthPlan.org

By clicking this link, you may be leaving the iCareHealthPlan.org website. Independent Care Health Plan (iCare) only provides these links and pointers for your information and convenience. When you select a link to an outside website, you are leaving the www.iCareHealthPlan.org website.

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