As indicated within the formulary, a Prior Authorization is required on certain medications before they will be covered.  Links to the Prior Authorization forms are located below.  We have also provided additional details regarding prior authorization requirements and step therapy criteria.

When the medications on our formulary used to treat a specific condition are not appropriate for a patient, you may request coverage of a non-formulary medication.  This type of request is called a Formulary Exception.   An exception may also be requested to the Step Therapy criteria when first-line agents are not appropriate for your patient, or to the Quantity Limit restrictions when the allowed quantity is not enough to adequately treat your patient’s condition.  The Prior Authorization forms located below may be used for formulary exceptions as well.  Supporting medical information must be submitted with any exception request.  The requests should be faxed to our Pharmacy Benefits Manager, MedImpact, at 858-790-7100.

Or, you may click here to submit a prior authorization through the web. You will be redirected to MedImpact's website.

Medicare Part D Coverage Determination Form

Medicare Part D Coverage Redetermination Form

Medication Request Form - Partnership Medicaid

The pharmacy benefit for members of iCare Medicaid SSI Plan and iCare BadgerCare Plus Plan is managed by the state of Wisconsin.  Please call the state provider services line at 1-800-947-9627 for information regarding drug coverage.

The pharmacy benefits for iCare Medicare Plans and iCare Family Care Partnership are managed by iCare.  Each plan utilizes a formulary approved by CMS which includes both brand and generic medications.  For certain medications, there are additional requirements for coverage or limits on the coverage.  These are indicated within the formulary as PA (Prior Authorization), ST (Step Therapy), or QL (Quantity Limit).  A list of our covered drugs, as well as descriptions of the additional requirements or limits on the coverage can be found in the Comprehensive Formulary.  Click here for information on prior authorization requirements or here for step therapy criteria.

iCare contracts with a company to offer Medication Therapy Management services to all iCare Medicare Plan members. Through them, specially trained Personal Pharmacists are identified in communities throughout Eastern Wisconsin. Learn More about our MTM program.

Independent Care Health Plan supports electronic prescribing for our Medicare members through Surescripts, an e-prescribing network.  Our e-prescribing program can provide you with prescription eligibility information, basic formulary information, and patient medication histories at the point of care.  You can securely access the information using standalone e-prescribing software or an Electronic Medical Record (EMR) that has been certified by Surescripts. Visit Surescripts's Website for more information.

For more information on pharmacies in our network, please search for pharmacies on our Find a Provider page. 

A preclusion list is a list of providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries.

The following page from CMS.gov answers questions, including:

• Why was the list created?
• Who is on the list?
• What happens if I'm on the Preclusion List?
• When did it go into effect?

Take me to the CMS.gov Preclusion List page