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To locate a Medicare Advantage coverage policy referenced in a letter you received, you can type the four-digit policy number (for example WI.PA-1223) in the Keywords search box below. If you cannot locate the policy here, please refer to Medical and Pharmacy Coverage Policies; iCare is a subsidiary of Humana, and coverage policies are also located on this Humana’s Medical and Pharmacy Coverage Policies page. iCare has also prepared some FAQs for Medicare Advantage coverage policies.

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iCare Medicare Provider Directory South-Central WI - updated 12/1/2024

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

iCare Medicare Provider Directory Southeast WI - updated 12/1/2024

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

iCare Medicare Provider Directory Northwest WI - updated 12/1/2024

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

iCare Medicare Provider Directory Northeast WI - updated 12/1/2024

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

2024 Comprehensive Formulary - updated 12/1/2024

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents

2024 Part D Prior Authorization Criteria - updated 12/1/24

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents

2024 Step Therapy Prescription Drug Criteria - updated 12/1/2024

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents

Medicaid-SSI-BC Plus Provider Directory-Western-WI Updated 12/1/24

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Provider Directories

Medicaid-SSI-BC Plus Provider Directory-South-Central WI Updated 12/1/24

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Provider Directories

Medicaid-SSI-BC Plus Provider Directory-Northeast WI Updated 12/1/24

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Provider Directories

Medicaid-SSI-BC Plus Provider Directory-Milwaukee-Updated 12/1/24

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Provider Directories

iCare Family Care Partnership Provider Directory - Updated 12/1/2024

Plans
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

2025 iCare Medicare Evidence of Coverage

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
  • Plan Information

2025 iCare FCP Evidence of Coverage

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

Non-Discrimination Notice

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Policies and Guidelines

Auxiliary Aids and Services Notice

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

2025 Stars Rating

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Plan Information

2025 Comprehensive Formulary

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership

2025 AEP Oct iCare Family Care Provider Directory

Plans
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

2025 AEP iCare Medicare Provider Directory Southeast

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

2025 AEP iCare Medicare Provider Directory Northeast

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

2025 AEP iCare Medicare Provider Directory Northwest

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

2025 AEP iCare Medicare Provider Directory Southcentral Southwest

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Directories

iCare Medicare Enrollment Form

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Applications

WI.PA-1250 - Cardiac Pacemakers

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

2025 iCare Medicare Annual Notice of Change

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
  • Plan Information

2025 iCare Medicare Summary of Benefits

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
  • Plan Information

2025 iCare FCP Annual Notice of Change

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

2025 iCare FCP Summary of Benefits

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

Medicare Multi-Language Interpreter Services

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines

Part D Transition Process

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents
  • Prior Authorization

Ombuds for BadgerCarePlus and SSI Medicaid HMO Members

Plans
  • ALL
Document Types
  • Claims
  • Grievances & Appeals

iCare Medicaid SSI and BadgerCare Plus Member News (Q2 2024)

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Health Education
  • Plan Information

Family Care Partnership Program Information Brochure

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Health Education
  • Plan Information
  • Programs
  • Self-Directed Supports

BC+ SSI Measure Year 2024 P4P Quality Measures

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Health Education
  • Internal Guidance for Providers
  • Policies and Guidelines

WI.PA-1158-Molecular Diagnostic Assays and Breath Testing for Transplant Rejection

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1124-Hip, Knee and Shoulder Arthroscopic Surgeries

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

Current iCare Prior Authorization List (PAL) - excel

Document Types
  • Prior Authorization

Current iCare Prior Authorization List (PAL) - pdf

Document Types
  • Prior Authorization

WI.PA-1051-Code Compendium (Wound Care)

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA.001-Outpatient Skilled Services, Home Health Services, Durable Medical Equipment, and Procedures PA Process

Plans
  • ALL
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1019-Balloon Dilation (Eustachian Tube and Sinus), Functional Endoscopic Sinus Surgery and RhinAer

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1017-Autologous and Allogeneic Bone Marrow Transplants/Peripheral Stem Cell Transplants/Umbilical Cord Blood Transplants

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1016-Autism Spectrum Disorders Diagnosis and Treatment

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1001-Ablation Techniques and Extracorporeal Shock Wave Therapy for Musculoskeletal Indications and Soft Tissue Wounds

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1045-Implantable Cardiac Devices for Hemodynamic Management

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1150-Left Atrial Appendage Closure and Cardiac Structural Defect Closure for Stroke Prevention

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1133-Implantable Infusion Pumps for Pain or Spasticity

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

Scope of Sales Appointment Confirmation Form

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Plan Information
  • Policies and Guidelines

CMS Appointment of Representative Form-Spanish

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Applications
  • Claims
  • Policies and Guidelines

2024 BadgerCare Plus & Medicaid SSI Member Handbook

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Plan Information

Part D Redetermination Request - Medicare

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents
  • Grievances & Appeals
  • Policies and Guidelines

Part D Redetermination Request - Family Care Partnership

Plans
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents
  • Grievances & Appeals
  • Provider Forms

COVID 19 Vaccine FAQ Flyer

Document Types
  • Health Education

2024 Dental Brochure - SSI/BC+ Medicaid

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information

2024 Vision Brochure - SSI/BC+ Medicaid

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Plan Information

Claim Form - LTC Professional - updated 1/2024

Plans
  • iCare Family Care Partnership
Document Types
  • Claims
  • Provider Forms

iCare Coverage Criteria FAQ Document

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1002-Achalasia And Gastroesophageal Reflux Disease Treatments

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1013-Artificial Intervertebral Disc Replacement

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1024-Blepharoplasty Blepharoptosis Repair and Brow Lift

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1026-Bone Graft Substitutes

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1040-Carotid Revascularization

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1041-Carpal Tunnel Syndrome Surgical Treatments

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1056-Complementary and Alternative Medicine

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1074-Electric Tumor Treatment Fields

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1078-Electrothermal Intradiscal Therapies

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1095-Genetic and Biomarker Testing for Alzheimer Disease

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1106-Genetic Testing for Hereditary Colorectal and Uterine Cancer

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1138-Intensity Modulated Radiation Therapy

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1141-Intraoperative Neurological Monitoring

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1147-Laparoscopic Hiatal Hernia Repair

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1152-Low Level Laser Therapy and High Power Laser Therapy

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1166-Negative Pressure Wound Therapy

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1169-Noninvasive Home Ventilators

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1185-Pharmacogenomics and Companion Diagnostics

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1210-Skysona (elivaldogene autotemcel)

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1212-Solid Organ Transplants

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1226-Transcatheter Valve Procedures

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1233-Varicose Vein Treatments

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1239-Zynteglo (betibeglogene autotemcel)

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1248-Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1252-Diagnostic Imaging

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-1256-Lung Biopsy and Resection

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-9002-Substance Use Disorder Inpatient Services

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

WI.PA-9003-Substance Use Disorder Partial Hospital Program Services

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • Prior Authorization

2024 iCare Medicare Summary of Benefits

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
  • Plan Information

2024 iCare Medicare Annual Notice of Changes

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
  • Plan Information

2024 iCare Medicare Plan Evidence of Coverage

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
  • Plan Information

Medicare Star Ratings

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines

2024 iCare Family Care Partnership Summary of Benefits

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

2024 iCare Family Care Partnership Evidence of Coverage

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

2024 iCare Family Care Partnership Annual Notice of Changes

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

Medicare Medication Reimbursement Claim Form

Plans
  • iCare Medicare Plan
Document Types
  • Formulary/ Pharmacy Documents

Diabetic Supplies FCP Medicaid 2024

Plans
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents

Inpatient Notification Form

Plans
  • iCare Medicare Plan
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Policies and Guidelines
  • Prior Authorization
  • Provider Forms

CMS Appointment of Representative Form-English

Document Types
  • Applications
  • Claims
  • Policies and Guidelines

FCP Medicaid Only Member Handbook-Updated 3/3/23

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
  • Plan Information

Notice of Privacy Practices

Document Types
  • Policies and Guidelines

Medicaid SSI Welcome Guide_Spanish_US

What to do in case of Emergency Spanish-US

Power of Attorney Brochure Spanish

Nurse Advice Line Brochure Spanish-US

Document Types
  • Health Education

Consent to Receive Electronic Communications

Plans
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines

Medicaid SSI Welcome Guide

Plans
  • iCare Medicaid SSI
Document Types
  • Benefit Information
  • Plan Information

BadgerCare Plus Welcome Guide

Plans
  • iCare BadgerCare Plus
Document Types
  • Benefit Information
  • Plan Information

FCP Self-Directed Supports Brochure

Plans
  • iCare Family Care Partnership
Document Types
  • Self-Directed Supports

FCP Self-Directed Supports Guidebook

Plans
  • iCare Family Care Partnership
Document Types
  • Self-Directed Supports

Medicare Member Reimbursement Request Form

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership

Opioid Education 2022 for iCare Medicare Plan members

Plans
  • iCare Medicare Plan
Document Types
  • Health Education

Opioid Education 2022 for Family Care Partnership members

Plans
  • iCare Family Care Partnership
Document Types
  • Health Education

Advance Directives - Power of Attorney, Living Will brochure

Plans
  • ALL

Medicaid Appointment of Representative Form-Grievence and Appeal.pdf

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare Medicaid SSI

Medicaid Appointment of Representative Form-Organization

Plans
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Medicaid Appointment of Representative Form-Person

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare Medicaid SSI

Incident Reporting Guide for Members

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Health Education

Understanding Abuse Neglect and Exploitation

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Behavioral Health
  • Health Education

Fraud Waste and Abuse Training

Document Types
  • Policies and Guidelines

Wisconsin Tobacco Quit Line Fact Sheet - Spanish

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Wisconsin Tobacco Quit Line Fact Sheet - English

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Part D Coverage Determination Request

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Formulary/ Pharmacy Documents
  • Prior Authorization
  • Provider Forms

iCare Limited English Proficiency Policy Statement

Document Types
  • Policies and Guidelines

BadgerCare Plus & Medicaid Mom & Baby Program

Plans
  • iCare BadgerCare Plus
Document Types
  • Health Education
  • Programs

What to do in Case of an Emergency

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Personal Medication List (blank)

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI

Nurse Advice Line Brochure

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Health Education

iCare Medicaid SSI Intensive Care Management brochure

Plans
  • iCare Medicaid SSI
Document Types
  • Programs

Appeals Request Form

Document Types
  • Claims
  • Policies and Guidelines

Equal Employment Opportunity Affirmative Action Policy Statement

Document Types
  • Policies and Guidelines

Request for a State Fair Hearing

Document Types
  • Applications
  • Policies and Guidelines

Ombuds Information (Hmong)

Document Types
  • Health Education
  • Policies and Guidelines

Medication Reconciliation Post-Discharge Form

Plans
  • ALL
Document Types
  • Formulary/ Pharmacy Documents
  • Provider Forms

Ombuds Information (Spanish)

Plans
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
Document Types
  • Health Education
  • Policies and Guidelines

Disclaimers

H2237_IC2203_M
Last Updated 10/15/22

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