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2024 Comprehensive Formulary - updated 11/1/2024

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

2024 Part D Prior Authorization Criteria - updated 11/1/24

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

2024 Step Therapy Prescription Drug Criteria - updated 11/1/2024

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

iCare Family Care Partnership Provider Directory - Updated 11/1/2024

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

iCare Medicare Provider Directory South-Central WI - updated 11/1/2024

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

iCare Medicare Provider Directory Southeast WI - updated 11/1/2024

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

iCare Medicare Provider Directory Northwest WI - updated 11/1/2024

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

iCare Medicare Provider Directory Northeast WI - updated 11/1/2024

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

Medicaid-SSI-BC Plus Provider Directory-Milwaukee-Updated 11/1/24

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

Medicaid-SSI-BC Plus Provider Directory-Northeast WI Updated 11/1/24

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

Medicaid-SSI-BC Plus Provider Directory-South-Central WI Updated 11/1/24

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

Medicaid-SSI-BC Plus Provider Directory-Western-WI Updated 11/1/24

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

WI.PA-1011 - Ambulatory Cardiac Monitoring Devices

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

WI.PA-1020 - Bariatric Surgery

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

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-1221 - Thyroid Surgeries (Thyroidectomy_Lobectomy)

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

WI.PA-1267 - Tecelra (afamitresgene autoleucel)

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

WI.PA-1182 - Peripheral Artery Revascularization of the Lower Extremities

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

WI.PA-1151 - Liquid Biopsy

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

WI.PA-1266 - Irreversible Electroporation

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

WI.PA-1139 - Interspinous Process Decompression Spacers

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

WI.PA-1097 - Genetic Testing

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

WI.PA-1089 - Gastric Pacing - Gastric Electrical Stimulation

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

WI.PA-1032 - Foot Surgical Procedures

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

WI.PA-1076 - Electrical Stimulators - Diaphragmatic Phrenic Nerve Functional and Neuromuscular

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

WI.PA-1250 - Cardiac Pacemakers

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

WI.PA-1034 - Cardiac Catheterization

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 Evidence of Coverage

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 Evidence of Coverage

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

Notice of Nondiscrimination

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
  • iCare BadgerCare Plus
  • iCare Medicaid SSI
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-9000-Psychiatric Inpatient Hospitalization

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

WI.PA-1249-Hospital Services (Long Term Care Hospitals (LTCH), Observation)

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

WI.PA-1241-Measurable (Minimal) Residual Disease Testing

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

WI.PA-1235-Videofluoroscopy, Dynamic MRI for Musculoskeletal Indications

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

WI.PA-1234-Ventricular Assist Device, Total Artificial Heart

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

WI.PA-1229-Ultraviolet Light/Laser Therapy for Skin Conditions

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

WI.PA-1225-Transcatheter Peripheral Vascular Stents-Chest, Abdomen and Pelvis

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

WI.PA-1201-Rheumatoid Arthritis: Biologic Markers and Pharmacologic Assessment

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

WI.PA-1186-Outpatient Rehabilitation (Physical Therapy, Occupational Therapy)

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

WI.PA-1180-Percutaneous Vertebroplasty, Kyphoplasty (Balloon-Assisted Vertebroplasty), Sacroplasty

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

WI.PA-1174-Ocular Surface Disease Diagnosis and Treatments

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

WI.PA-1173-Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments

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

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-1154-Lymphedema - Diagnosis and Treatments

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

WI.PA-1130-Hyperthermia for Treatment of Cancer

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

WI.PA-1128-Hyperbaric Oxygen Therapy, Topical Oxygen Therapy

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-1081-Erectile Dysfunction and Peyronie's Disease Treatments

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

WI.PA-1066-Deep Brain Stimulation and Cortical Stimulation

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

WI.PA-1053-Cold and Heat Therapy Devices

Plans
  • iCare Medicare Plan
  • iCare Family Care Partnership
Document Types
  • Policies and Guidelines
  • 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-1048-Code Compendium (Musculoskeletal and Neurologic)

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-1010-Allograft Transplantation of the Knee

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

WI.PA-1062-Coronary CT Angiography Fractional Flow Reserve with CT, Calcium Scoring

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

WI.PA-1064-Cosmetic and Reconstructive Surgery

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

WI.PA-1039-Cardioverter Defibrillators/Cardiac Resynchronization Therapy

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

WI.PA-1135-Infertility Evaluation and Treatment

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

WI.PA-0574-Molecular Testing for HLA- B*27 for Ankylosing Spondylitis

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

WI.PA-1175-Omisirge (omidubicel-onlv)

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-1000-Inpatient Hospital Services

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-1007-Airway Clearance Devices

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-1014-Athletic Pubalgia Surgery

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

WI.PA-1021-Benign Prostatic Hyperplasia Treatments

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-1028-Brachytherapy

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

WI.PA-1029-Breast Imaging

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

WI.PA-1030-Breast Reconstruction

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

WI.PA-1031-Bronchial Thermoplasty

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

WI.PA-1033-Capsule Endoscopy

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

WI.PA-1035-Cardiac Electrophysiological Studies and Cardiac Catheter Ablation

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

WI.PA-1037-Cardiac Single- Photon Emission Computed Tomography

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-1054-Colorectal Cancer Screening and Surveillance

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-1057-Comprehensive Genomic Profiling and Genetic Testing for Solid Tumors

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

WI.PA-1063-Percutaneous Coronary Intervention

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

WI.PA-1065-Cryoablation

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

WI.PA-1067-Diagnostic Esophagogastroduodenoscopy or Esophagoscopy

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

WI.PA-1070-Drug Testing

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

WI.PA-1072-Dynamic Spinal Stabilization Devices

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

WI.PA-1073-Elective Aorta and Iliac Artery Aneurysm Repair

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-1080-Endobronchial Valves for Emphysema

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

WI.PA-1084-Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

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

WI.PA-1085-Fecal Incontinence Evaluation and Treatments

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

WI.PA-1087-Fusion Imaging for Cancer Indications

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

WI.PA-1088-Fusion Imaging for Noncancer Indications

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

WI.PA-1091-Gender Affirmation Surgery

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

WI.PA-1092-Gene Expression Profiling for Cancer Indications

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-1096-Genetic and Coagulation Testing for Noncancer Blood Disorders

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

WI.PA-1100-Genetic Testing for Hereditary Breast Ovarian Pancreatic and Prostate Cancer

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

WI.PA-1101-Genetic Testing for Hereditary Cancer

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

WI.PA-1102-Genetic Testing for Cardiac Conditions

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-1109-Genetic Testing for Diagnosis of Inherited Conditions

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

WI.PA-1112-Genetic Testing for Hereditary Ataxias

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

WI.PA-1119-Glaucoma Surgical Treatments

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

WI.PA-1122-Headache and Occipital Neuralgia Treatments

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

WI.PA-1123-Hip Arthroplasty

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1132-Implantable and Non-Implantable Hearing Devices

Plans
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Document Types
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WI.PA-1137-Injections for Chronic Pain Conditions

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1138-Intensity Modulated Radiation Therapy

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1140-Peripheral Nerve Stimulators

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1141-Intraoperative Neurological Monitoring

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1145-Knee Arthroplasty

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1146-Molecular Biomarkers for Prostate Cancer Risk Stratification

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1147-Laparoscopic Hiatal Hernia Repair

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1152-Low Level Laser Therapy and High Power Laser Therapy

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1156-Microwave Thermotherapy

Plans
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Document Types
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WI.PA-1161-Molecular Markers in Fine Needle Aspirates of Thyroid Nodules

Plans
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Document Types
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WI.PA-1163-Multianalyte Assays with Algorithmic Analyses for Cancer Indications

Plans
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Document Types
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WI.PA-1165-Multiplex Pathogen Identification Panels for Infectious Disease

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1166-Negative Pressure Wound Therapy

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1168-Neuroablative Techniques for Chronic Pain

Plans
  • iCare Medicare Plan
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WI.PA-1169-Noninvasive Home Ventilators

Plans
  • iCare Medicare Plan
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WI.PA-1171-Noninvasive Tests for Hepatic Fibrosis

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1172-Obstructive Sleep Apnea and Other Related Sleep Disorders Nonsurgical Treatments

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1176-Orthognathic Surgery

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1177-Orthotics

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1178-Osteochondral and Subchondral Defects Surgery

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1185-Pharmacogenomics and Companion Diagnostics

Plans
  • iCare Medicare Plan
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WI.PA-1188-Platelet Derived Growth Factors for Wound Healing

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1193-Prostatectomy

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1194-Prosthetics

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1195-Proton Beam Neutron Beam and Carbon Ion Radiation Therapy

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1198-Radiofrequency Tumor Ablation

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1200-Reduction Mammaplasty

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1204-Serological and Fecal Testing for Inflammatory Bowel Disease

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

WI.PA-1207-Shoulder Arthroplasty

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

WI.PA-1208-Skin and Tissue Substitutes

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

WI.PA-1215-Spinal Cord Stimulators

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

WI.PA-1216-Spinal Decompression Surgery

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1217-Spinal Fusion Surgery

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1218-Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1220-Temporomandibular Disorders

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

WI.PA-1223-Tinnitus Treatments

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

WI.PA-1226-Transcatheter Valve Procedures

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1227-Cranial Electrical Stimulation

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

WI.PA-1230-Urinary Bladder Dysfunction

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1231-Uterine Fibroid Surgical Treatments

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

WI.PA-1232-Vagus Nerve Stimulation

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

WI.PA-1233-Varicose Vein Treatments

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1239-Zynteglo (betibeglogene autotemcel)

Plans
  • iCare Medicare Plan
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Document Types
  • Policies and Guidelines
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WI.PA-1240-Genetic Testing for Hematologic Malignancies and Suspected Myeloid Disorders

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1248-Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1248-Gene Expression Profiling for Noncancer Indications

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1251-Transesophageal and Transthoracic Echocardiogram

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1252-Diagnostic Imaging

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-1254-Excision and Mastectomy for Breast Lesions

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1255-Facility Based Sleep Studies

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
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  • Prior Authorization

WI.PA-1259-Early Prostate Cancer Detection

Plans
  • iCare Medicare Plan
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Document Types
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  • Prior Authorization

WI.PA-1260-Special Stains

Plans
  • iCare Medicare Plan
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Document Types
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WI.PA-9001-Psychiatric Partial Hospital Program Services

Plans
  • iCare Medicare Plan
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Document Types
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  • 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
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Document Types
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WI.PA-CAR-T-Pharmacy Policy-Tecartusbrexucabtagene autoleucel-

Plans
  • iCare Medicare Plan
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Document Types
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2024 iCare Medicare Summary of Benefits

Plans
  • iCare Medicare Plan
Document Types
  • Benefit Information
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2024 iCare Medicare Annual Notice of Changes

Plans
  • iCare Medicare Plan
Document Types
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2024 iCare Medicare Plan Evidence of Coverage

Plans
  • iCare Medicare Plan
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  • Benefit Information
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Medicare Star Ratings

Plans
  • iCare Medicare Plan
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2024 iCare Family Care Partnership Summary of Benefits

Plans
  • iCare Family Care Partnership
Document Types
  • Benefit Information
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2024 iCare Family Care Partnership Evidence of Coverage

Plans
  • iCare Family Care Partnership
Document Types
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2024 iCare Family Care Partnership Annual Notice of Changes

Plans
  • iCare Family Care Partnership
Document Types
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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
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Inpatient Notification Form

Plans
  • iCare Medicare Plan
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CMS Appointment of Representative Form-English

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

Plans
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Notice of Privacy Practices

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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
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Consent to Receive Electronic Communications

Plans
  • iCare Family Care Partnership
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Medicaid SSI Welcome Guide

Plans
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BadgerCare Plus Welcome Guide

Plans
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FCP Self-Directed Supports Brochure

Plans
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  • Self-Directed Supports

FCP Self-Directed Supports Guidebook

Plans
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Medicaid Interpreter Services

Plans
  • iCare BadgerCare Plus
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Medicare Member Reimbursement Request Form

Plans
  • iCare Medicare Plan
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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
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Medicaid Appointment of Representative Form-Organization

Plans
  • iCare Family Care Partnership
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Medicaid Appointment of Representative Form-Person

Plans
  • iCare Medicare Plan
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Incident Reporting Guide for Members

Plans
  • iCare Medicare Plan
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Document Types
  • Health Education

Understanding Abuse Neglect and Exploitation

Plans
  • iCare Medicare Plan
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Document Types
  • Behavioral Health
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Fraud Waste and Abuse Training

Document Types
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Wisconsin Tobacco Quit Line Fact Sheet - Spanish

Plans
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Wisconsin Tobacco Quit Line Fact Sheet - English

Plans
  • iCare Medicare Plan
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Part D Coverage Determination Request

Plans
  • iCare Medicare Plan
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Document Types
  • Formulary/ Pharmacy Documents
  • Prior Authorization
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iCare Limited English Proficiency Policy Statement

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BadgerCare Plus & Medicaid Mom & Baby Program

Plans
  • iCare BadgerCare Plus
Document Types
  • Health Education
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What to do in Case of an Emergency

Plans
  • iCare Medicare Plan
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Personal Medication List (blank)

Plans
  • iCare Medicare Plan
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Nurse Advice Line Brochure

Plans
  • iCare Medicare Plan
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iCare Medicaid SSI Intensive Care Management brochure

Plans
  • iCare Medicaid SSI
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Appeals Request Form

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Equal Employment Opportunity Affirmative Action Policy Statement

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Request for a State Fair Hearing

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  • Applications
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Ombuds Information (Hmong)

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  • Health Education
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Medication Reconciliation Post-Discharge Form

Plans
  • ALL
Document Types
  • Formulary/ Pharmacy Documents
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Ombuds Information (Spanish)

Plans
  • iCare BadgerCare Plus
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Document Types
  • Health Education
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Disclaimers

H2237_IC2203_M
Last Updated 10/15/22

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