Know about Prior Authorizations

A prior authorization is an OK from your health plan that is required before you can receive certain services. This OK helps you get the most for your health care dollar.

If your care needs an OK, call your health care provider. Your provider has to ask us for an OK. If an OK is not requested, your benefits may be reduced or denied. A review is completed by providers and registered nurses to give the OK.

Below are services that require an OK:

  • Behavioral Health levels-of-care, including:

    Inpatient Psychiatric

    Intensive Outpatient

    Psychiatric Rehabilitation

    Detoxification

    Day Treatment

    Psychological Testing

    Substance Abuse Rehabilitation

    Applied Behavioral Analysis

    Sub-acute Psychiatric

    Crisis Stabilization

    Anger Management Supportive Employment

    Sub-acute Substance Abuse

    Residential Treatment Facility

    Supported Housing

    Electroconvulsive Therapy

    Partial Hospitalization

    Crisis Respite

     

  • Chiropractic services
  • Durable Medical Equipment (purchase or rental of more than $500)
  • Food supplements and substitutes including formulas taken by mouth for adults age 21 years and older
  • Home Health Care
  • Hospice Care – both inpatient and outpatient
  • High-Technology Imaging (HTI): CT, CTA, MRI, MRA, MR Spectroscopy, PET Scans and Nuclear Cardiology
  • Inpatient Hospital Services (including Neonatal Intensive Care Unit (NICU) care)
  • Orthotics (purchase amount/allowed amount of more than $200)
  • Out-of-Network services
  • Outpatient Services including, but not limited to:
    • Arthroscopy
    • Endoscopy
    • Laparoscopic Cholecystectomy (Lap Chole)
    • Bariatric surgery
    • Musculoskeletal system surgery
    • Respiratory surgery
    • Cardiovascular surgery
    • Digestive system surgery
    • Nervous system surgery
  • Outpatient Therapy (Physical, Occupational & Speech)
  • Pharmacy Medicines (certain specialty medicines, listed in the chart below)

    Notes:

    • Other medicines may be included. This list is subject to change.
    • Some Diagnostic & Therapeutic medicines require an OK.
    • A generic drug is a copy of a brand-name drug. It that has the same dosage, safety, strength, quality performance and intended use as a brand-name drug. A generic drug is also more affordable than a brand-name drug.

      Trade Name

      Generic Name

      Code

      Achtar

      Corticotropin

      J0800

      Amevive

      Alefacept

      J0215

      Avastin

      Bevacizumab

      J9035

      Erbitux

      Cetuximab

      J9055

      Flolan

      Epoprostenol Sodium

      J1325

      Lanreotide Acetate

      Somatuline

      J3490

      Orencia

      Abatacept

      J0129

      Remicade

      Infliximab

      J1745

      Remodulin

      Treprostinil Sodium

      J3285

      Rituxan

      Rituximab

      J9310

      Synagis

      Palivizumab

      C9003, J9303

      Tysabri

      Natalizumab

      J2323

      Vectibix

      Panitumumab

      J9303, C9235

      Velcade

      Bortezomib

      J9041

      Xolair

      Omalizumab

      J2357

      Epogen and Procrit

      Epoetin Alfa

      J0885 (non-ESRD use),
      J0886 (ESRD use)

      Aranesp

      Darbepoetin Alfa

      J0881 (non-ESRD use),
      J0882 (ESRD use)

  • Plastic Surgery: All services performed by a plastic specialist including:
    • Abdominoplasty/Panneculetomy
    • Blepharoplasty
    • Breast reduction
    • Treatment for Gynecomastia
    • Reconstructive Repair for Pectus Excavatum
    • Breast Reconstruction
    • Vein Ligation
    • Laparoscopic Cholecystectomy
    • All non-covering, investigational or cosmetic procedures and services
  • Pregnancy: Obstetrical care (OB) care during Pregnancy requires an OK
  • Prosthetics (purchase amount/allowed amount of more than $200)
  • Skilled Nursing Facility (SNF)
  • Transplants and Transplant Evaluations
  • Wheelchairs: All new requests for wheelchairs and accessories require an OK regardless of purchase or rental price.

Specialist

A specialist is a health care provider who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist, who treats heart diseases. Another kind of specialist is an oncologist, who treats cancer. There are many kinds of specialists.

Your primary care provider (PCP) may send you to a specialist for care. This is called a referral. If your PCP wants you to go to a specialist, he or she will set up the appointment with the specialist for you.

If the specialist is not in our Provider Network, your PCP must get an OK from us first. If you have co-pays, your co-pay is the same even if the specialist is Out-of-Network.

Important! You cannot go to a specialist without your PCP’s referral. We will only pay for a specialist visit if your PCP sends you. But please note:

  • No PCP referral is needed to see a women’s health care provider for well-woman checkups.

    A women’s health care physician is called an OB/GYN. Other women’s health care providers may include nurse practitioners and physician assistants. The women’s health care specialist must still be in our network. More information about women’s health care is in Part 2 of your member handbook.

  • No PCP referral is needed to see a behavioral health provider for mental health, alcohol or substance abuse services.


This page was updated on Aug 05, 2014