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INDIANA HEALTH COVERAGE PROGRAMS (ICP) TESTOSTERONE PRIOR AUTHORIZATION REQUEST FORM MD wise Fax to: (858) 7907100 c/o Impact Healthcare Systems, Inc. Attn: Prior Authorization Department 10181 Scripts

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Indiana Health Coverage Programs (IHCP) provide health care to eligible low-income individuals and families in the state of Indiana through a variety of programs, including Medicaid.

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Individuals and families who wish to enroll in Indiana Health Coverage Programs based on their income, age, disability, or other qualifying criteria are required to file.

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Applicants must report personal information such as name, address, income, household size, and any other relevant information that affects eligibility for health coverage.

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